CPR #4 Diabetes Mellitus He had a 26 year history of Type I diabetes mellitus, poorly controlled most of the time. was negative for diabetes mellitus. …
Endocrine 26
1pm-2pm
Feb 15, 1999
Dr Pasmantier
Evelyn Rondinel 732-0942
CPR 4 Diabetes Mellitus
I have included the case into this transcript along with her comments so
you can read this without the syllabus p 177-178
Patient History:
This is a case of a 31 year old man who is admitted to the hospital with a
3 day history of weakness and discoloration of his right foot, associated
with constant pain He denied chest pain, shortness of breath, GI
symptoms, chills, or trauma to the foot or leg He had a 26 year history
of Type I diabetes mellitus, poorly controlled most of the time He had
smoked two packs of cigarettes a day since age 15 5 years ago he received
his first laser therapy for retinopathy, but he lost most of his vision in
his left eye secondary to hemorrhage and retinal detachment For the past
ten years he had progressive loss of sensation in both feet and he was
hospitalized two year ago for amputation of his right great toe, because of
a foot ulcer with osteomyelitis He had been impotent for 6 years
Proteinuria was detected ten years ago He had been hypertensive for the
past 8 years Medications included NPH and regular insulin,
taken before
breakfast and supper, Quinapril angiotensin converting enzyme inhibitor,
doxazosin peripheral alpha-adrenergic blocker His family history was
negative for diabetes mellitus His father died at 47 of a myocardial
infarction
Risk factors for coronary vascular disease, or macrovascular disease and
microvascular disease:
Diabetes for 26 years Anything over 10 years you start to see
macrovascular problems
Smokes cigarettes since age 15 32 pack-year history: decreases small
vessel circulation, increases platelet adhesiveness, etc
Laser treatment to eye, and retinal detachment indicates that blood sugar
is not controlled controlled means HbA1c of 7, blood glucose of 150 or
less
Neuropathy
Impotency, suggesting vascular problems
Proteinuria, which suggests microvascular problems in kidney
Hypertension, which goes along with diabetic nephropathy
Strong, positive family history
Physical Exam
-He was a thin man, in moderate distress from leg pain Vital signs: BP
100/50 usual BP 145/90
Hypotension in an ordinarily hypertensive patient is very worrisome,
suggesting failure of heart to generate pressure
-Pulse 96 and regular; temp 99F
-Eyes: EOM
extraocular movement full; the right fundus showed
proliferative retinopathy; the left fundus could not be visualized He
could read with his right eye, but had only light perception on his left
-Heart: soft systolic murmur at the left sternal border Lungs and abdomen
- unremarkable
-Extremities: both legs showed absent pedal pulses
-Loss of hair on the lower legs and toes
-Multiple light-brown macules over the shins
These macules are necrobiosis lipoidica diabeticorum, seen in long-
standing diabetes, indicative of disturbances in the microcirculation of
the skin They are common in people with diabetes over 20 years It can
break down and ulcerate, but here they just describe pigment changes
-The entire right foot was bluish-black in color and mildly edematous
Suggests gangrene
-The right calf was tender Indicates non-viable tissue
-Neurological: he was alert and oriented
-All modalities of sensation were diminished in both feet, and
sensation was essentially absent in the toes bilaterally Strength
appeared intact Ankle jerks were absent bilaterally
Laboratory
-Hematocrit was 39, WBC 17,000 with 78 PMN, 2 bands
Elevated white
count, and left shift elevation of PMN Hematocrit is
moderately decreased, which probably indicates an infection; but this is
the least of his problems
-BUN was 34, creatinine 21, Elevated; creatinine2 means he has less than
half his renal function
-sodium 138, potassium 53, Mildly elevated; many patients are
hyponutremic, hypoaldosteronism, usually in patients with diabetic
nephropathy this condition raises potassium, and has to be monitored
because some medications can increase the serum potassium
-chloride 106, Bicarbonate 20, Mildly decreased, blood gas values would be
useful here to detect mild ketoacidosis or lactic acidosis; or if bicarb
was normally at that level, it would mean mild to moderate renal
insufficiency with a metabolic acidosis
-glucose 296 mg/dL Very elevated
-Urinalysis showed 3 glucose, 4 protein, no ketones No ketones means not
in diabetic ketoacidosis; but he obviously has poor glucose control and is
probably has diabetic nephropathy with gross proteinuria
-Hemoglobin A1c was 112 normal less than 7 current studies say 6,
but 112 is very high,
-cholesterol 269 mg/dL goal is 200,
-triglycerides 281 mg/dL goal is 200, some data indicates 150 to
decrease
cardiovascular events, -HDL 30 mg/dL low, typical of diabetic;
LDL is 183, which is high In some intervention trials, average LDL of 139
in diabetic population; LDL/HDL should be 3-35, in this case is 61
-Creatinine kinase was 4500 with 26 MB normally 200, and MB is
elevated, indicating acute myocardial damage; moderate to large infarct
-Electrocardiogram: compared to prior EKGs, there were new Q-waves in the
anterolateral and inferior leads, with ST elevation and T-wave inversion in
these same leads signs of acute myocardial infarction Anterior MI is
quite serious because anterior wall is where most of heart pumping
capability is
Hospital Course
Doppler studies showed complete occlusion of the right popliteal artery,
and he was anticoagulated with heparin Although the right foot was felt to
be non-viable, amputation was temporarily postponed because of the acute
myocardial infarction Two days after admission, he suddenly became
hypotensive and suffered a cardiac arrest from which he could not be
resuscitated
The Rest of the Lecture
This was a typical case of hyperglycemia over the long haul, exemplifying
long-term effects of diabetes At 26 years, distinction between
Type I and
Type II diabetes is not too relevant, only duration really matters
Microvascular Disease best associated w/blood sug level Macrovascular
Disease
Retinopathy blindness Heart Attack
Nephropathy renal failure Strokes
Neuropathy Amputation Peripheral vascular
disease
In Type 1, the leading cause of death is complications due to blood sugar
itself, hyperglycemia or hypoglycemia in diabetic ketoacidosis Second
most common cause is end-stage renal disease
Type 2, leading cause of death ischemic heart disease
Health Care Cost of Diabetes
Annual health cost is 2000-4000 per year for tight control of blood sugar,
everything included Cost of acute complications is 6000 per year
Chronic complications from diabetes over 10 or 20 years brings cost up to
12,000 - end-stage kidney disease, amputation, etc are very expensive
This is the argument for paying for prevention
Interventional Studies : DCCT Study diabetic control complications
trial
Objective: The DCCT was done to determine whether intensive treatment will
produce a normal blood sugar with a low frequency and severity of
diabetic
complications
1441 type 1 diabetic patients were enrolled
The patients were randomized to two study groups
conventional therapy
intensive therapy
Mean age of randomization 27 years
Intensive therapy
monitoring blood glucose at least 4 times a day
monthly HbA1c measurements 6 or less is normal; mean glucose of 120
mg/dL
Goals for this group were:
target blood glucose was 70-120 average
post-prandial of less than 180
Weekly 3AM glucose levels were also done to make sure that low levels
of glucose 65mg/dl did not occur
They had as a target of HbA1c to be in the normal range
605but they found that this was nearly impossible to achieve
with type 1 diabetics Only 5 of people could achieve these
levels
Conventional therapy
Blood sugar was monitored 1-2X per day
HbA1c levels were taken quarterly
Goals of this therapy:
was to eliminate symptoms of glycosuria and elevated blood glucose
to have no elevated ketones or ketonuria
to have no hypoglycemia
to maintain normal growth development and a normal body weight
What the patients were able to achieve
Before enrolling in the
study the patients had HbA1c levels averaging
98
The patients on conventional therapy had 91 levels while in the study
which corresponds to a mean glucose level of 231
The patients on intensive therapy achieved HbA1c levels of 72 note
that this is not yet normal; only 5 got to pre-study goal, which
corresponds to a mean glucose level of 155 The intensive therapy could
not achieve the goals desired 605 but they did much lower than the
conventional therapy
Now the recommendation is to keep the HbA1c levels at about 7
Extrapolation of the DCCT study
Extrapolation of the study showed that there was a marked increase in
retinopathy, nephropathy, neuropathy, and microalbuminuria once patients
have HbA1c levels above 8 Retinopathy correlates best that is, worst
for the patient
A non-significant result due to only a 7 year study was that there was
also a 41 decrease in coronary events in the intensive therapy group
Macrovascular results really need a longer study, more than 10 years,
because the number of events was too small
Significant results were that the intensive therapy group had 63 less
retinopathy, 39 less nephropathy, and 60
less neuropathy
Conclusions
Long-term outcome for patients with Type 1 diabetes will be measurably
improved with treatment with intensive therapy This is the standard of
care accepted now; doctors would have tried to intervene in todays
example long before the outcome
10 year prospective study in Denmark
Several hundred Type 1 patients who had developed microalbuminuria Showed
a postive correlation between HbA1c and microalbuminuria
Lewis Study:
1992 trial of Type 1 patients with serum creatinine 2, and some
proteinuria, but less than 500 mg/day
200 on placebo usual BP medications,
200 on captopril usual plus 25 mg Captopril
Captopril reduced the risk of end-stage renal disease or death
Indicated that microalbuminuria or proteinuria should be treated with
aggressive therapy with ACE inhibitors
How should we have managed this patient?
Much more aggressively The chart decribes the necessary actions to take
Close communication with the patient concerning day-to-day levels of
insulin are very useful fax and email are good for this
|Action |Frequency |Evaluation |
|Scheduled office visits|Quarterly |Goals:
BP, blood levels|
| | | |
| | |Examine eyes, feet |
|Test FPG |As often as necessary |Glycemic control |
|Test HbA1c |Quarterly or as |Glycemic control |
| |necessary | |
Other points:
the abnormal lipid profile should have been treated with a diet and HMg
CoA reductase inhibitor LDL should have been 130, not 183
He was probably not on enough ACE inhibitor, considering the renal
function problems common in her view to be on wrong dose
Also, one wants to keep protein 1000 mg/day For microalbuminuria
300 mg/day you want to lower this into the normal range 30 mg/day
Comprehensive dilated eye exams are useful; patients diagnosed more than
5 years, which undergo this comprehensive eye exam regular, go blind
much more rarely than others
Finally, two injections of insulin is TOO LITTLE, for almost all
patients He should have been on three or four, or perhaps an insulin
pump
|Action |Patient Criteria |Evaluation
|
|Assess lipid profile |Adult patients with |Total cholesterol |
| |abnormal lipid profiles|Fasting Triglycerides |
| | |HDL Cholesterol |
| | |LDL Cholesterol |
|Assess Renal Function |All diagnosed patients |Microalbuminuria |
| | |Albumin/Creatinine in |
| | |urine or serum |
| | |creatinine |
|Perform comprehensive |All patients: |Retinopathy |
|dilated eye exam |Diagnosed for 5 years | |
| |Older than 30 years | |
| |Any patients with | |
| |visual | |
| |symptoms/abnormalities | |
Heart Disease and Diabetes Link:
Studies show that diabetes significantly increases risk of heart failure
Mr Fit Trial:
This study examined
cardiovascular mortality in diabetes patients It had
350,000 patients, 5100 with diabetes Looked at three risk factors:
1 cholesterol 220;
2 systolic BP 140;
3 smoking
Risk factors increased risk of CVD death in both diabetics and non-
diabetics But diabetes had a synergistic effect, increasing risk more
than just additively That is, it is more important than simply being just
another risk factor
Paris Prospective Study
This was an 11 year study with over 7000 patients, 900 with diabetes It
showed that CHD death increased when triglycerides were greater than 150,
in patients with diabetes
Framingham Study largest study
Showed that people with diabetes have lower HDL, higher triglycerides that
is, higher VLDL This is the typical lipid pattern in diabetics It is
an Athrogenic ? pattern
ADA Recommendations for Lipid Levels slide a bit old, numbers will change
Recommends LDL 130 Some argue for diabetes patients to be treated as
secondary prevention patients, ie, that we should require LDL less than
100 Clearly, though, our fellow was way too high In addition,
triglycerides should be 200 or even 150, according to Paris study
