Interactive diabetes case 20: A 76-year-old man with long-standing type 2 diabetes, orthostatic hypotension, and recurrent syncope
- Lloyd Axelrod, MD
Lloyd Axelrod, MD
- Associate Professor of Medicine
- Harvard Medical School
A 76-year-old man with a 27-year history of type 2 diabetes is referred to you because of orthostatic hypotension and recurrent syncope. For the last six months the patient has had increasingly frequent episodes of lightheadedness, usually related to rising from a lying or a sitting position; instability on his feet; and profound weakness occurring at various times of day and night. In the last three months he has fallen one to two times a week on standing up. On at least four occasions he lost consciousness. On one occasion, he struck his head on a toilet seat, with a laceration that required multiple sutures.
He has been in the emergency department of his community hospital five times and admitted to the hospital twice. On each occasion the blood glucose level (obtained by the patient's wife, the emergency medical technician, or the emergency department laboratory) was over 100 mg/dL. Each time an acute myocardial infarction was ruled out and the patient was treated with volume repletion although neither volume depletion nor a cause of volume loss was specifically identified.
During the second admission a diagnosis of adrenocortical insufficiency was considered. A cosyntropin stimulation test was performed and the patient was discharged on prednisone 5 mg every morning. This did not alleviate his symptoms. The plasma cortisol level one hour after cosyntropin 250 micrograms intravenous (IV) was subsequently reported as normal at 24 micrograms/dL (662 nmol/L). The glucocorticoid was stopped after several weeks. The patient has been confined to home by his symptoms, and his wife and son are concerned that he will suffer serious injury in a fall.
The patient has had type 2 diabetes for 27 years. His metabolic control had never been optimal, with glycated hemoglobin (A1C) values in the 8 to 9 percent range. He has refused to take insulin. His most recent A1C is 8.2 percent. In recent years he has developed background diabetic retinopathy, distal sensory neuropathy, microalbuminuria, and hypertension.
The patient's medications are metformin 1000 mg twice a day, glipizide 10 mg before breakfast and supper, lisinopril 10 mg every morning, hydrochlorothiazide 25 mg every morning, simvastatin 40 mg every evening, aspirin 81 mg a day, alfuzosin (Uroxatral) 10 mg every morning, a multivitamin, and calcium 600 mg with vitamin D 400 international units twice a day.