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NP Rounds

NP Rounds. NP Rounds December 8th DIABETES MANAGEMENT When you have tried everything?. Background. 60 year old aboriginal gentleman

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NP Rounds

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  1. NP Rounds NP Rounds December 8th DIABETES MANAGEMENT When you have tried everything?

  2. Background • 60 year old aboriginal gentleman • Co managed with physician for 1st year due to co-morbidities and because we both provide care in the aboriginal community – last year & half I have been his primary care provider • As diabetes educator I do all the insulin starts in our practice and make recommendations for medication changes on all our diabetes patients

  3. HPI • Dx diabetes x5 years with underlying CAD, HTN, Dyslipidemia, obesity, GERD, iron deficiency anemia, diverticular disease, hematuria, remote hx asthma, ventral hernia • Initial meds ramipril and pravastatin • Several serious admissions to hospital with chest pain, then escalating blood sugars • Initial diet controlled to metformin • Several admissions to hospital for chest pain then angina

  4. HPI continued • Unable to consider insulin start prior or between initial admissions to hospital • Trial of glicazide with metformin • Diabetes and insulin therapy vs aboriginal belief system • Last admission to hospital blood sugars 30 switched from NPH to pre-mix 30/70 and discharged from hospital day after • Support in a remote community vs discharge planning

  5. HPI • Regular follow up complicated by camp job after losing job as D&A counsellor at band office • FMH – children with addictions, 18 y/o daughter pregnant, wife chronic illness, grown up children and grandchildren moving back into home, serious financial issues • Social hx – residential school survivor, recovered alcoholic, serious gambling issue

  6. Details of Diabetes Management in last year • I started him on NPH insulin at hs then bid with improvement in BG for approx 6 mos • Then managed on metformin and pre-mixed insulin post discharge from hospital for about 8 months – given intensive education, support visits both office/home, seen by diabetes nutritionist • Began to fail on this regime – increased wt gain, increased family and work stressors, return to poor eating habits despite regular follow ups

  7. Diabetes Management continued • Having low blood sugars with labile swings and rising blood sugars overall • Unable to get approval for lantus insulin from Health Canada even with special authority • Unable to use other oral drugs i.e. avandia unacceptable potential side effects • Unable to get new drugs and pay for ongoing • Assisted patient to register for fair pharmacare, why when aboriginal • Band getting some benefits privately for some members of the community

  8. Diabetes continued • Discussed rapid insulin – worry due to in and out of camp • Began to exercise and eat differently at camp with some improvement in blood sugars but worse when at home • Considered lantus again, may actually be safer and less rigid management than pre-mix • Discussed with CDA in CR, also seen by endo • Patient wanting to try lantus and willing to pay

  9. What happened • Switch to lantus – with 20% reduction based on N insulin dosage of pre-mix • Really better to go straight across with switch but returning to camp too soon with minimal supervision despite having camp nurse • Regular follow up each time out of camp with initial good improvement once matched N dose with increase by 4 units bid • Stabilized BG for approx 6 mos with a return to rising blood sugars

  10. What is next Trying to convince patient we needed to switch insulin based on presentation by Victoria endo • Peaks and troughs with obese type 2 • Go back to the basics with NPH and rapid with metformin • Patient resistence +++, less regular follow up as difficult to catch up with patient • 2nd strategy leave lantus add rapid – 3 months to convince

  11. Currently • Meds: • metformin 500 mg bid • Ramipril 5 mg od • Pravastatin 40 mg od • Fe glu 300 mg tid • ASA 81 mg od • Insulin Lantus 47 units bid • Humalog 5 units ac meals • Last labs: • A1c 8.0 improved, FBG 7.8, Lipids and renal function okay, no hematuria

  12. Currently • Ferritin 4 • MCV 78 low • RCDW 18.3 • Sat 0.13 • TIBC 78 • Reticulocyte count normal • OB x 3 normal • Pending colonscopy

  13. Ongoing care • Revisit all co-morbidities especially CAD • Wt loss, stress management, residential school support, regime in camp/home • Improvement in BG with humalog, patient added with minimal problems • What to do when BG start rising • Basic pillars of diabetes management • Social situation/stressors • Switch to Humulin N from lantus – covered by benefits

  14. Other Ideas for Management • Other insulins • New and old oral drugs • Other options

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