PATY is a 15-year old black-and-white tuxedo-marked kitty with a white mustache and weighs a robust 30 pounds! So whenever I take him to the veterinarian for his yearly vaccinations, I must first sit through the “obese cat lecture.” Well, all I can tell you in my defense is that he has spent most of his life lying near his dish awaiting his next meal and it’s not like I have been feeding him potato chips on the side.
The vet is set on proving to me he has diabetes. As you may also imagine stuffing a thirty pound cat into a carrier box to drive him to his yearly physical is not an easy task. As a matter of fact it usually takes me and my daughter working together to safely push him into the box and to be able to shut the door. He protest loudly, placing his hind legs on each side of the box, and we inevitably end up laughing at his resistance and the futility of our efforts. After several tries, of course, we ultimately win and PATY is very frustrated and makes guttural moaning sounds while riding in the car all the way to the vet’s office.
When we arrive at the vet’s office, first PATY is immediately weighed and I then find myself once again receiving my yearly “obese cat lecture.” Then we re-stuff PATY back into his box and have to wait in a waiting room with other larger pets, most of which are dogs. Finally, after PATY is called back to the exam room, his blood is drawn, he receives his vaccinations, and we return home.
The next day, I receive a call to bring PATY back to the vet’s office as his blood glucose was 350 mg/dL! The vet questions me as to if PATY is flooding the litter box when he urinates or urinating frequently in the house, etc. I let her know he has not been doing anything differently. We return to the vet and PATY’s blood is again drawn, but this time the vet draws a Frutosamine level.
Answer the following questions about PATY:
–How is weight status such as obesity determined in cats?
–What aspects of PATY’s life lead him to hyperglycemia?
–What does one learn from a Frutosamine level in pets?
–When might a Frutosamine level be used for humans?
–On a less serious note, do you think PATY is more handsome than Grumpy cat? Do you think Grumpy cat deserves his own commercial? Could you envision PATY on a “Got Milk” commercial? Well enough about my cat!
Bb) CASE 2: The patient, 47-year-old JH, was diagnosed with Type 2 diabetes 2 years ago. As a
mother of 2 teenage children and owner of a local health food store, she took the news seriously
and was committed to improving her health. Her practitioner suggested that she see a dietitian to
review her meal plan. Although she found it challenging, she was able to achieve good glycemic
control through improved meal planning and physical activity, including enrollment in a local
fitness center. However, at 5’8″ and 197 lbs, JH continues to have a body mass index (BMI) of
30 kg/m2
, indicating clinical obesity. She has no personal or family history of cardiovascular
disease (CVD).
At her last exam, you noted, her blood pressure was 128/72 mmHg and she had an A1C of 7.9%.
She had been able to maintain an A1C under 7% with lifestyle modification, but her values have
gradually increased during the last 6 months. Her lipid profile is as follows: total cholesterol
(TC) = 255 mg/dL, low-density lipoprotein cholesterol (LDL-C) = 97 mg/dL, high-density
lipoprotein cholesterol (HDL-C) = 45 mg/dL, and triglycerides = 176 mg/dL. Her liver enzymes
and creatinine were normal and she has no evidence of microalbuminuria. Her eye exam was
also normal, and fasting SMBG showed glucose values between 130 and 150 mg/dL. JH is not
currently taking any medications to treat her Type 2 diabetes.
- After asking JH to monitor her blood glucose levels more carefully, it is found that she
has marked postprandial hyperglycemia, with values ranging from 210 mg/dL to 290
mg/dL. Targeting this problem may allow her to achieve an A1C of <7%. Describe a
management plan to reach this goal. - Which therapies would you choose to target postprandial hyperglycemia in JH?
- How would you involve the patient in her own management?
The Role of the Patient – The patient is the key player in the diabetes care team, and should be
trained and empowered to prevent and treat hypoglycemia, as well as to adjust medications with
the guidance of healthcare providers to achieve glycemic goals. Without the patient’s interest and
dedication, all treatment plans are much more likely to fail, no matter how well designed the
regimen. Therefore, proper patient motivation and education are key elements in the
implementation of a successful treatment plan.
Cc) Case 3: PK is a 56-year-old woman who has had Type 2 diabetes for 10 years. She is 5’5″, and
weighs 174 lbs, with a BMI of 29 kg/m2
. Her A1C level is 8.9%. Her blood pressure is 128/76
mmHg. Her lipid profile is as follows: TC = 189 mg/dL, LDL-C = 79 mg/dL, HDL-C = 58
mg/dL, and triglycerides = 260 mg/dL, on statin therapy. Liver function tests reveal normal ALT
and AST levels, and her creatinine is 1.2 mg/dL. An initial microalbuminuria level was 220
mcg/mg, and a follow-up was 198 mcg/mg.
An eye exam 3 months ago revealed proliferative diabetic retinopathy (PDR) requiring laser
therapy. PK was diagnosed with coronary artery disease 1 year ago, and underwent an
angioplasty with stent placement. PK has a stressful job as a financial analyst, and has poor
eating habits and little time to monitor her diabetes. Occasional testing shows a preprandial
glucose range typically 100 to 200 mg/dL. She does not monitor postprandially. PK is currently
treated with metformin 1000 mg twice daily and glyburide 20 mg daily.
At some point in the progression of Type 2 diabetes, there may be a need to add another
antidiabetes treatment option to an existing 2-medication regimen. For patients using metformin
and sulfonylurea, for example, options might include a TZD, exenatide, or insulin. Each of these
therapeutic options would reduce CV risk, but for different reasons.
- Please discuss the pros and cons of these options.
- Discuss the following common issues in advanced diabetes management:
• Targeting Fasting Versus Postprandial Hyperglycemia.
Even after adding another class of non-insulin therapy to her oral regimen, PK’s glucose testing
results show preprandial glucose levels of 100 to 200 mg/dL. The postprandial glucose levels are
about 40 to 80 points higher than preprandial values. Her A1C is 8.9%. Therefore, you are
considering insulin therapy. There are many potentially suitable insulin regimens for a patient
like PK, with numerous insulin formulations available to tailor the action patterns to match the
patient’s lifestyle. - Which insulin would you choose for PK at this point WITH RATIONALE?
Sample Solution
