1 Patient, 3 Assessments: Which Is Best?

Anne L. Peters, MD


October 29, 2010

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Hi, I'm Dr. Anne Peters, Director of the Clinical Diabetes Programs at the University of Southern California, and today I'm going to talk to you about the opinions of 3 experts on 1 patient. I was at a panel the other day and we were asked questions at the end of our talks, and one of the questions was a case that I'm going to share with you.

The case is a 59-year-old man who has type 2 diabetes and cardiovascular disease; he'd had a myocardial infarction about 4 years before. He was not exactly lean, he was 5' 10" and weighed 260 pounds; his blood pressure was 150/90 mm Hg, he was on basically everything the doctor could think to put him on -- metformin, glimepiride, and pioglitazone. He was on 70/30 insulin, a total of about 100 units of insulin a day (60 units in the morning and 40 units before dinner) and his A1C was 10.4% Nothing that this doctor could do would get this guy's A1C down.

Additionally, his LDL [low-density lipoprotein] cholesterol was 150 mg/dL, and his triglycerides were 245 mg/dL. This was the case. The first panel member thought about the patient, and he said, "Forget about glycemia, don't worry about treating it. You're never going to get this patient under better control, all you've got to do is focus on the cardiovascular risk factors, so get his blood pressure down to less than 130/80, get his LDL down to less than 70, make sure he's on aspirin, really make sure he's maximally cardiovascularly risk-modified and leave him at his A1C of 10, that's the best you're ever going to get, and if you get him too low, you're going to cause hypoglycemia and then you're going to have trouble."

I think that was a good response in the sense that you really do need to maximally risk-modify this patient, in terms of cardiovascular disease, but at 59, I'd like to think that he's got the chance to live long enough to experience microvascular complications, such as retinopathy, neuropathy, and nephropathy, and I want to prevent that. I know I can prevent that by lowering his blood glucose levels.

The second panel member said the following, "What I'd do is add liraglutide (Victoza®) to the patient's regimen." Frankly, this is something that's commonly done. It's off-label, because it's not yet approved to add Victoza® to insulin, but the person answering this figured as follows: if he added in once-a-day Victoza®, and started tapering down the insulin, maybe on less insulin, the patient would eat less, would not have quite so much hypoglycemia, and that the Victoza® would allow the patient to reduce his insulin dose, reduce his glucose levels, and then also perhaps lose weight. I think that's a great idea and I think Victoza® might really help here.

The caveat about using it, as I said it's not FDA-approved. The other thing is that you have to be really careful in this man to reduce his insulin adequately, and make sure he's following up with fingerstick blood sugars. You might even want to get him tapered off the glimepiride so that he's not on a drug that can also cause hypoglycemia. If he could ideally be dropped down to, for example, metformin, 30 mg of pioglitazone, maybe basal insulin, like Lantus® once a day and Victoza® once a day, you might really help him in terms of reducing his risk for hypoglycemia and get his blood glucose levels down, but that might not work.

The third panel member said the following, "I'd abandon worrying about glucose levels and I'd abandon the cardiovascular risk for the moment and I would just send him to bariatric surgery." That's also a pretty good option, and in fact, it makes a lot of sense. The patient, as I said, is relatively young, his body mass index is 37 kg/m2, and bariatric surgery really works. It could be a very significant improvement in this man's life, both in terms of his glucose control, as well as his macrovascular risk, blood pressure, lipids, etc.

Now I personally don't like bariatric surgery. It's not that I don't think it works, I think it works great, and I have my patients go for bariatric surgery, but I don't like it in the sense that it just seems so wrong to have to cut somebody up and rearrange their intestines and their gastrointestinal tract to make them lose weight so things get better, but there are many patients where that's really the only answer because you can't get them where you want them with other measures.

I think, oddly, all these answers are right and they were all from different perspectives. What I would do with this patient is really work on modifying his cardiovascular disease risk, I would try adding in the off-label Victoza®, seeing if I could get him off the 70/30 insulin and on to basal insulin, get his blood sugars and his weight down, and if that didn't work, or if the patient was really interested in bariatric surgery, I'd let him have that as an option. I'd talk about it with him -- talk about risks and benefits. I think it's important to note that in a patient on this many antidiabetes medications, his beta cells may not be able respond entirely to weight loss and he may end up still on some medication for his diabetes, but undoubtedly, he'd be on a lot less.

That just goes to show that we all have different perspective with the same ultimate goal, which is obviously getting this man to target in all ways and trying to maintain that over time. This has been Dr. Anne Peters for Medscape.


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