Type 2 Diabetes Management Case Study: Maria

Type 2 Diabetes Management Case Study: Maria


(Soft gentle music) – [Speaker] Our first case
study highlights Maria, who is a 45 year-old Hispanic female, who has had Type two
diabetes for 15 years, and is treated with
Metformin 1000 milligrams bid and Glipizide 20 milligrams bid. She has gained 10 pounds and
is having difficulty losing it. The patient reports not remembering when she had her last foot exam, which is recommended to be done annually. Her last eye exam was six months ago, so she’s up to date on the
recommended annual eye exam. She is taking Lisinopril 10 milligrams for her blood pressure management, and Atorvastatin 40 milligrams for her cholesterol management. Her A1C range from 7.5 to nine percent Her A1C range from 7.5 to nine percent in the past two to three years. She reports a weight gain of 10 pounds, frustrated with the
inability to lose weight despite diet and exercise. She does not smoke. Let’s watch as Doctor
Basina meets with Maria. – Good morning, Maria. I am so pleased you are
here in the clinic today. I would like first to just find out I would like first to just find out what’s the goal for our visit today, what would you like to
achieve during today’s visit. – Let’s see, recently, I’ve been trying to lose 10 pounds that
I gained a while back, but despite eating better
and getting exercise, I just can’t seem to lost it, and I’ve just been feeling really like frustrated and worried that it might be tied to my diabetes or maybe my medication? – Hm, I can totally
understand your frustrations, and I’m glad that weight
loss is a great goal, but before we talk about the medications and the diabetes control, let me try to get some more information about your past medical history, about the family history,
and past medications that you’ve used for diabetes treatment. – [Speaker] We see from the
patient’s medical record that a diagnosis her A1C was 8.9 percent and after three months of the
initial Metformin treatment her A1C dropped to eight percent, which was still elevated. At this point, Glipizide
five milligrams bid was added to her regiment. The dose was gradually
titrated to 20 milligrams bid. Her A1C dropped to 7.1 percent, however, as her blood-sugar improved, she started having symptoms of feeling shaky, foggy, and sweaty. Her blood sugars were in the low range at the time of these symptoms. She reported that she began to compensate with frequent snacks
which likely contributed to weight and a subsequent rise in A1C. Her dietary choices at
the time, hypoglycemia, were culturally embedded,
consisting of food she had been eating her whole life. She was unaware that these
foods were a contributing factor to her unsuccessfully-managed diabetes and weight fluctuations. This brings us to today, as she continues to struggle with that weight gain, and is presented with an A1C above 8.2 percent for over the past year. Maria’s diabetes therapy
needs to be adjusted, but first, Doctor Bacina
needs to learn more about Maria’s lifestyle and diet. – Thank you for sharing
this information with me, this is really helpful for me to know. I can see that you had a blood work done about a month ago, and your hemoglobin A1C was elevated, it was 8.3 percent. Can you tell me a little bit more about which medicines are you taking now and how often of what the doses are? – Yeah, so I still am taking Metformin, I take a thousand milligrams at breakfast and at dinner when I remember. Sometimes it got to
dinner and I just don’t have my pills on me. I stopped taking the
Glipizide because I noticed that it was making my blood sugars low and sometimes when, even when I’m watching my diet and trying to exercise more my diet and trying to exercise more that I’m still feeling shaky and low. Well, like recently, I’m on a vacation and I tested my blood
sugars and I was up to 372, so I got scared, but, you know, I think that’s because eating really unhealthy, I was eating like chips,
and sweets, and rice, and those aren’t things that
I have so often at home, I don’t know it just
feels like it’s so hard to keep my blood sugars in range, you know, not to high, not to low. Sometimes I miss my medications, but I’ve noticed that
when I miss my Glipizide I get high, like into the
two hundreds and above, but then conversely
when I take my Glipizide I feel like I’m so hungry, like I could eat a whole cow. – Mm, so what what is your usual schedule at home for the meals? Do you eat more like small
meals throughout the day, more like a grazing
type of the food intake, or you’re eating your regular meals and you don’t snack during the day, and do usually do
normally snack at bedtime? Because, the reason I’m asking and I want to get all this information is that when we come up
with a medication schedule I want to make sure it fits your schedule and your needs, so it can be
easier for your lifestyle. – Okay, yeah, so usually I have breakfast like on the way to work,
or when I get there. Sometimes I have lunch
if I have enough time, but honestly I think my
largest meal is at night and yeah, I do snack at night, and that’s usually because, you know, it’s usually when I’m feeling relaxed that I realize how hungry I am. – Thank you for sharing
this information with me, this is really helpful, and I understand, it’s difficult to make
adjustments in your schedule, and everyone, as human
beings, it’s difficult, and we all tend to do that, but what we’ll try to
do is to try to reduce your cravings at night because consuming those higher calorie and
high carb snacks at night make your blood sugars go up also when you’re not moving
after eating those snacks, that causes the weight
gain and blood sugars stay up overnight and continue being elevated in the morning, but we really want to work with you to try to make its easier for you and to find the medication regiment that would best fits your schedule. – [Speaker] Let’s review
what we’ve learned so far. Maria is on a dual-therapy regiment of Metformin and Glipizide,
which is a sulfonylurea. Her A1C has improved somewhat, but it’s clear Glipizide
isn’t working for Maria. In addition to her difficulty adhering to the daily medication,
it’s affecting her ability to control her diet. Before we add an additional
agent to Maria’s therapy, we need to see if adjustments can be made such as replacing Glipizide
with another agent and referring Maria to a dietician who can help her come up with
alternative foods to eat, and a better lifestyle management plan. Looking at options for
different therapeutic agents, a GLP one receptor, such as dulaglutide, is a suitable alternative to Glipizide. It is a once-weekly, injectable medication that does not cause hypoglycemia, promotes weight loss, and
provides an improvement in glycemic control. However, Maria has
expressed a fear of needles, and prefers to avoid taking injections. Many patients have a fear of
taking insulin injections, so it is important to explain
that a GLP one agonist is unlike a daily insulin injection. The benefit of the medication outweighs the inconvenience of the injection, but broaching this topic
requires sensitivity and a reassuring approach. Let’s see how Doctor Basina outlines all the benefits to the patient in order to overcome her fear of the injections. – Based on the information
you have shared with me today, I think that the best treatment option would be to start you on the injections, which I totally understand, and know you previously expressed to me that your concerns and
fear with the injections, but let me just explain you first. So this it the medicine
that you would take only once per week, and
the needle is small, and the injection is really not causing much of the discomfort,
and most of the time patients would say that
checking the blood sugars way more uncomfortable
than taking the shot. The needle is small, and the medicine is really, most of the
time, very well tolerated. We would just need to
check with your insurance to make sure that the medicine is covered, but I would also like to ask you to check your blood sugars
a couple times a day and maybe before breakfast, before dinner so I will get a little more information about your blood sugar
readings throughout the day, which will help me to
make further adjustment, if needed, in your medication. – Okay, well, I mean, I feel
a little bit uncomfortable, because I’m so scared of needles. Where would I have to do the injections, and are there side
effects to the medication? – Yeah, so we will definitely give you a lot of information about the medicine, I will have the nurse come and show you how to administer injections,
if you want to try it, you can try it in the clinic. We have training pens, and you would be able to do it yourself. If you have any concerns, or if you feel that it’s too complicated,
we can always do it again, and have another session with the nurse, another teaching session. So the medication can be administered either in the stomach
or the thigh or the arm, and again, it’s a very easy
medicine, it’s just once a week, and the medication
provides a lot of benefits, which are, one of the
advantages is to help you which are, one of the
advantages is to help you with the blood sugar
control, reduce your craving, help with the weight loss, help to achieve your goal in hemoglobin A1C, and there are some
side-effects from the medicine. One is a little bit
uncomfortable with the injection like any injection, but
again, as we say before like any injection, but
again, as we say before that the needle is really small, and it’s really easy to give. The medicine also can cause a little bit of a stomach upset and some nausea, and that’s only in the beginning, and it usually goes away, and if there is something that doesn’t work for you with this medication,
we can always change it or come up with a different regimen. – Okay, I can do that, I
mean if it’s only once a week and the needle’s small,
I can give it a try, but someone’s gonna show
me how to do it, right? – Absolutely, I will have the nurse come into the room and show you, demonstrate you how to
take those injections, and you will try it yourself. To make sure you remember
after you leave the clinic, we will provide you with a link that you would be able to watch the video as a reminder how to
take those injections. Also, I would suggest and would like you to schedule an appointment
with my dietician, and she can go over different food choices and snack choices that will make you feel and snack choices that will make you feel not hungry throughout the day, but choose sort of the
healthier food and snacks for your meals and some snacks
during the day and night. – [Speaker] The patient
presents back in three months, after seeing the registered dietician and certified diabetes educator,
and starting the GLP one. She has lost nine pounds
and her A1C is 6.8. She states that she did
realize her previous diet including eating out for
lunch and some dinners was so high in calories and carbohydrates. She’s made changes to her meal plan, including making healthier
choices when eating out, packing her lunch two
to three times per week, and using a phone app to
track her food intake. Let’s see how Maria’s check-in with Doctor Bacina is going. – Good morning, Maria. I am so glad to see you today
and to give you good news that I have your blood
test for hemoglobin A1C, that I have your blood
test for hemoglobin A1C, and the level came down to 6.8 percent, and the level came down to 6.8 percent, which is great success. I also saw that you were able to lose nine pounds which is wonderful. So you did a great, great job. Tell me, what do you think
helped you the most to succeed, and what do you think
about those injections, because I remember, in the beginning, you had lots of concerns about
taking shots of dulaglutide. What do you think about those now? – Well, first of all,
thank you Doctor Bacina for all your help. Yeah, I was pretty nervous
about the needles at first, but then, since they were kind of small, it just, I realized over
time that it got easier. I think the thing that
was the most helpful was the dietician like you recommended, was just working with her to realize how many calories I was eating that my body didn’t need, and figuring out that I was going to a lot of carbohydrates because a lot of the foods that are my sort of go-to foods
are really high in carbs, so with that support, I
was able to figure out how to start eating better. – Sure, and this, you’re not alone, this is very common, and
I hear this all the time. – But now I’ve learned that
I can still eat the foods that I’m used to, I just
need to find lighter, lower-carb ways to enjoy
that, or to prepare them, and I’m also not going out as much to eat which has been good for
my diabetes and my wallet, and I’m trying to just stay stocked-up on lower-carb, lower-calorie options that are good for me and delicious. I’ve started to make changes, I am now eating cauliflower rice, seasoned with cilantro and
garlic, and it’s delicious. I’ve also started using curled red bell peppers for my tacos. I guess I just never realized that I could fill up on vegetables, and they’re actually delicious. – Excellent, I’m so glad to hear that you found foods and
choices that work for you. – Oh, and I’ve also been
using this new phone app that helps me track my
calories and my food intake, so I feel like with that, and
all the different food choices that I’ve been making,
making better choices that I just feel like I’m eating healthier and doing better altogether. – Thank you for your
such a hard and great job that you did and I am very
happy with the success. To make sure that we are sustainable with our achievements,
I would like to order some quarterly hemoglobin A1C levels. We would also monitor
your kidney function, electrolytes, we would
be periodically checking your lipo panel, which
will be a fasting test, and also once a year we will
check the little urine sample to make sure that the
kidneys are working well and not spilling some protein
as an effective diabetes. (gentle music) – [Speaker] For now,
Doctor Bacina and Maria have found a dual therapy that combines diet and medications that work for her. They will continue to monitor her levels including A1C every three to six months. This concludes case one. When you are ready, please
advance to case two, Marcus, in the course menu.