NP RoundsDecember 8th

DIABETES MANAGEMENTWhen you have tried everything?

60 year old aboriginal gentleman Co managed with physician for 1st year

due to co-morbidities and because we both provide care in the aboriginal community – last year & half I have been his primary care provider

As diabetes educator I do all the insulin starts in our practice and make recommendations for medication changes on all our diabetes patients

Dx diabetes x5 years with underlying CAD, HTN, Dyslipidemia, obesity, GERD, iron deficiency anemia, diverticular disease, hematuria, remote hx asthma, ventral hernia

Initial meds ramipril and pravastatin Several serious admissions to hospital with

chest pain, then escalating blood sugars Initial diet controlled to metformin Several admissions to hospital for chest

pain then angina

Unable to consider insulin start prior or between initial admissions to hospital

Trial of glicazide with metformin Diabetes and insulin therapy vs

aboriginal belief system Last admission to hospital blood sugars

30 switched from NPH to pre-mix 30/70 and discharged from hospital day after

Support in a remote community vs discharge planning

Regular follow up complicated by camp job after losing job as D&A counsellor at band office

FMH – children with addictions, 18 y/o daughter pregnant, wife chronic illness, grown up children and grandchildren moving back into home, serious financial issues

Social hx – residential school survivor, recovered alcoholic, serious gambling issue

I started him on NPH insulin at hs then bid with improvement in BG for approx 6 mos

Then managed on metformin and pre-mixed insulin post discharge from hospital for about 8 months – given intensive education, support visits both office/home, seen by diabetes nutritionist

Began to fail on this regime – increased wt gain, increased family and work stressors, return to poor eating habits despite regular follow ups

Having low blood sugars with labile swings and rising blood sugars overall

Unable to get approval for lantus insulin from Health Canada even with special authority

Unable to use other oral drugs i.e. avandia unacceptable potential side effects

Unable to get new drugs and pay for ongoing Assisted patient to register for fair

pharmacare, why when aboriginal Band getting some benefits privately for some

members of the community

Discussed rapid insulin – worry due to in and out of camp

Began to exercise and eat differently at camp with some improvement in blood sugars but worse when at home

Considered lantus again, may actually be safer and less rigid management than pre-mix

Discussed with CDA in CR, also seen by endo Patient wanting to try lantus and willing to

pay

Switch to lantus – with 20% reduction based on N insulin dosage of pre-mix

Really better to go straight across with switch but returning to camp too soon with minimal supervision despite having camp nurse

Regular follow up each time out of camp with initial good improvement once matched N dose with increase by 4 units bid

Stabilized BG for approx 6 mos with a return to rising blood sugars

Trying to convince patient we needed to switch insulin based on presentation by Victoria endo

Peaks and troughs with obese type 2 Go back to the basics with NPH and rapid

with metformin Patient resistence +++, less regular follow

up as difficult to catch up with patient 2nd strategy leave lantus add rapid – 3

months to convince

Meds: metformin 500 mg bid Ramipril 5 mg od Pravastatin 40 mg od Fe glu 300 mg tid ASA 81 mg od Insulin Lantus 47 units bid Humalog 5 units ac meals

Last labs: A1c 8.0 improved, FBG 7.8, Lipids and renal

function okay, no hematuria

Ferritin 4 MCV 78 low RCDW 18.3 Sat 0.13 TIBC 78 Reticulocyte count normal OB x 3 normal Pending colonscopy

Revisit all co-morbidities especially CAD Wt loss, stress management, residential

school support, regime in camp/home Improvement in BG with humalog,

patient added with minimal problems What to do when BG start rising

Basic pillars of diabetes management Social situation/stressors Switch to Humulin N from lantus – covered by

benefits

Other insulins New and old oral drugs Other options