d******u
发帖数: 10 | 1 上课的一个糖尿病例：
Blood glucose 378, A1c: 14 ( current )
Blood Glucose 140, A1C: 10 ( 2 years ago)
Weight 218lb (99kg)
Medications:
Metformin 1000mg, 1TAB BID Levemir (long acting insulin), 35units QD
怀疑noncompliance 导致血糖失控. 我是应该:
１。 告诉病人坚持吃药，打INSULIN, do nothing else
２。 增加INSULIN的剂量， 4 units every 3 days until FBG<180, then 2 units
every 3 days until in target range
３。 增加其他糖尿病口服药
４。１+２， １+２+３
Also Anion Gap 15mmol/dL, should I order lab for Ketone and pH to check if
he develops acidosis? By the way, his kidney function is good, Na and Cl are
a little bite low. Na 134 [136-145], Cl 94 [101-108]
He also has HTN, and is on four HTN drugs, is salt restriction in diet a
good recommendation for him since his Na is low? Because Low salt diet could
make Na level lower.
Thanks!!!!!! | J*********4
发帖数: 1274 | 2 恩，这题我也不太懂哦。
勉强选2吧。病人血糖控制不好，有AG acidosis, 是不是要停metformin，只用胰岛素?
专家们请~~ | a*********d
发帖数: 2763 | 3 is this a real case or an exam case? answer can vary depending on the
situation. there is absolutely no uniform way to treat a DM patient, lots of
factors should be considered, therapy should be tailored individually.
in this case, if it is a real case, nothing should be done until you look at
the patient's daily glucose data. you SHOULD NOT adjust regimen just base
upon A1c.
it is important to know where the problem is, fasting hyperglycemia?
postprandial hyperglycemia? does he/she have hypoglycemia? pt can have a
very high A1c but frequent hypoglycemia.it is very dangerous to adjust
regimen without knowing those details.
if fasting hyperglycemia, increasing levemir is appropriate (actually lantus
might be better), if postprandial hyperglycemia, either add premeal insulin
or add GLP-1 agents.
as far as hyponatremia, patients with significant hyperglycemia frequently
present with such mild hyponatremia, it is related to electrolytes shifting
within through cells, no need to correct.
last, i assume this is a type 2 Dm since pt is on metformin. therefore you
don't need to worry about checking ketones, they rarely go DKA.
上课的一个糖尿病例：
Blood glucose 378, A1c: 14 ( current )
Blood Glucose 140, A1C: 10 ( 2 years ago)
Weight 218lb (99kg)
Medications:
Metformin 1000mg, 1TAB BID Levemir (long acting insulin), 35units QD
怀疑noncompliance 导致血糖失控. 我是应该:
１。 告诉病人坚持吃药，打INSULIN, do nothing else
２。 增加INSULIN的剂量， 4 units every 3 days until FBG<180, then 2 units
every 3 days until in target range
３。 增加其他糖尿病口服药
４。１+２， １+２+３
Also Anion Gap 15mmol/dL, should I order lab for Ketone and pH to check if
he develops acidosis? By the way, his kidney function is good, Na and Cl are
a little bite low. Na 134 [136-145], Cl 94 [101-108]
He also has HTN, and is on four HTN drugs, is salt restriction in diet a
good recommendation for him since his Na is low? Because Low salt diet could
make Na level lower.
Thanks!!!!!!
【在 d******u 的大作中提到】
: 上课的一个糖尿病例：
: Blood glucose 378, A1c: 14 ( current )
: Blood Glucose 140, A1C: 10 ( 2 years ago)
: Weight 218lb (99kg)
: Medications:
: Metformin 1000mg, 1TAB BID Levemir (long acting insulin), 35units QD
: 怀疑noncompliance 导致血糖失控. 我是应该:
: １。 告诉病人坚持吃药，打INSULIN, do nothing else
: ２。 增加INSULIN的剂量， 4 units every 3 days until FBG<180, then 2 units
: every 3 days until in target range
| J*********4
发帖数: 1274 | 4 谢谢！学习了！
of
at
【在 a*********d 的大作中提到】
: is this a real case or an exam case? answer can vary depending on the
: situation. there is absolutely no uniform way to treat a DM patient, lots of
: factors should be considered, therapy should be tailored individually.
: in this case, if it is a real case, nothing should be done until you look at
: the patient's daily glucose data. you SHOULD NOT adjust regimen just base
: upon A1c.
: it is important to know where the problem is, fasting hyperglycemia?
: postprandial hyperglycemia? does he/she have hypoglycemia? pt can have a
: very high A1c but frequent hypoglycemia.it is very dangerous to adjust
: regimen without knowing those details.
| d**o
发帖数: 618 | 5 As to your last sentence, low salt diet does not make [Na] level lower.
Hyponatremia is a misnomer, the low [Na] has much much more to do with water
than sodium. Follow the salt restriction advice would be wise. | d******u
发帖数: 10 | 6 谢谢各位大拿指导，非常非常有帮助。这是一个真实的病例，我们下周要见病人，导师
让先自己分析一下病历。
The current blood glucose was obtained in BMP lab work. Thus, I suppose it
is fasting BG. Pt checks his BG sporadically, and reports no symptomatic
hypoglycemic episodes in last visit.
Still some questions I am not clear:
Why is Lantus better than Levemir? Anion Gap is 15, but I don’t have his pH
. Is it metabolic acidosis? If yes, Metformin should be discontinued, since
it is contraindicated in metabolic acidosis.
If both FBG and postprandial BG are higher than the target, do I want to
increase long acting insuline dose and also add bolus insulin?
Many thanks!!! | a*********d
发帖数: 2763 | 7 although levemir is marketed as long acting insulin, multiple studies showed
it works better as a bid dose. therefore if pt is using once a day
injection, lantus will be a better option, unless hypoglycemia is a concern.
what's pt's bicarb? AG of 15 is not that bad,repeat BMP see if any
improvement.i would not stop metformin just because of that, unless he is
going for procedure,with low GFR or active CHF, etc.
if fasting and postprandial both high, i will adjust fasting first,once
fasting reaches the target, then you can focus on postprandial.
education, diet control and weight loss, are always the most important.
pH
since
【在 d******u 的大作中提到】
: 谢谢各位大拿指导，非常非常有帮助。这是一个真实的病例，我们下周要见病人，导师
: 让先自己分析一下病历。
: The current blood glucose was obtained in BMP lab work. Thus, I suppose it
: is fasting BG. Pt checks his BG sporadically, and reports no symptomatic
: hypoglycemic episodes in last visit.
: Still some questions I am not clear:
: Why is Lantus better than Levemir? Anion Gap is 15, but I don’t have his pH
: . Is it metabolic acidosis? If yes, Metformin should be discontinued, since
: it is contraindicated in metabolic acidosis.
: If both FBG and postprandial BG are higher than the target, do I want to
| d******u
发帖数: 10 | 8 Thanks!!!! Your explaination is so clear. His Bicarb is normal 25mmol/L,
Creatinine 1mg/dL, eGFR>60. But he had a history of MI, and got stent placed
. | b******8
发帖数: 1251 | 9 GLP-1 is injection, if the patient doesn't want too much injection, he can
use DPP-4 inhibitor drugs such as Januvia, but it's a little bit less
effective than GLP-1.
lantus is better because it's a real long acting insulin, once daily dosing.
you need the patient's daily blood glucose reading to know what you should
do. you can read the AACE guideline.
why is he on 4 antiHTN drugs? can you post them? BTW, I am not a MD student,
I am in pharmacy school and will go to rotation soon. | d******u
发帖数: 10 | 10 HTN drugs:
1. LISINOPRIL 40MG 1TAB QD
2. HCTZ 25MG 1tab QD
3. Amlodipine 10mg 1TAB QD
4. Carvedilol 25mg 1TAB BID
Carvedilol is also for his coronary artery disease.
His blood pressure reading are from 130/80 to 140/90 with those drugs. |
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