Case Studies
| Real Life Cases |
| Case Study - IV |
| It is therefore necessary to control hyperglycemia adequately in order to minimise the risk of development and progression of diabetic complications and provide symptom relief. The modes of therapy in diabetes in the order of their chronology and importance are : |
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| In the person with type 2 diabetes drug therapy usually consists of using one or more drugs with differing mechanisms of action in order to attain the target blood glucose levels in the fasting and 2 hour post-meal state. |
| The usual drug of choice in the younger and leaner patient is an insulin secretagogue e.g. a sulphonylurea type of compound that augments insulin release from the pancreas |
| In older patients (who are more prone to the adverse effects of hypoglycemia) and in obese patients (who have greater insulin insensitivity) an insulin sensitiser like metformin may be preferred as the drug of first choice. |
| A very important longitudinal study called the United Kingdom Prospective Diabetes Study [UKPDS] that began in 1977 and whose definitive report was published in 1998 has clearly proved that : |
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| Management of the Current State : |
| As Manoj Kumar was receiving the maximal recommended dose of SU and Metformin, his doctor decided that it was time to add insulin to the treatment plan. He informed Manoj Kumar that he would require insulin injection for proper control of the diabetic state. Manoj Kumar who was normally an exemplary patient; and who had listened to and followed his doctor’s advice in all respects up till now; was very much disturbed when his doctor informed him regarding the necessity to add insulin therapy in order to control the diabetic state adequately. He pleaded with his doctor to avoid prescribing insulin at all costs an agreed to buy any oral medication that the doctor would recommend. His doctor realised that Manoj Kumar was troubled by his prior (mis)conceptions regarding insulin injection, and therefore decided to take an empathetic approach in managing the situation. |
| The doctor asked Manoj Kumar to state the reasons why he did not wish to take insulin injection after assuring him that it was indeed required, and that no oral drug would be able to produce a more beneficial effect than insulin. After due thought and consideration Manoj Kumar could list his reasons for trying to avoid insulin therapy, which were as follows : |
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| The vehemence with which Manoj Kumar resisted the doctors well-intentioned advice to start insulin therapy gave the clue to the doctor that this patient would not take insulin in spite of the doctor’s advice. Therefore it was necessary for the patient himself to realise that insulin was really required by him and would provide him benefit that other medications could not. Hence the doctor decided that a participative approach in which the physician empowers the patient to realise the best course of action after trying out other possible courses would be the only method that would help the patient. He therefore made a deal with Manoj Kumar. |
| The doctor once again informed Manoj Kumar about the pathology and progressive nature of type 2 diabetes and the hazards of uncontrolled or inadequately controlled hyperglycemia. Manoj Kumar had to agree with the doctor’s statements because he had heard the same several times during his educational sessions and by reading the books provided by his physician on the patient’s role in self-management of diabetes. |
| The doctor also clarified to Manoj Kumar that insulin is the definitive replacement therapy for diabetes and most patients invariably require insulin therapy after a variable period of having had diabetes because all types of oral drugs for diabetes are known to have a limited efficacy and finally insulin is the only treatment that helps control plasma glucose levels adequately. Adequate control of blood glucose levels is essential to minimise the frequency and severity of development of diabetic complications. |
| As Manoj Kumar was however opposed to insulin therapy for a variety of reasons the doctor informed him that he would attempt to restore glycemic control to within the acceptable range by adding another oral agent to the regimen and observing the effects at the end of 1 month. He requested Manoj Kumar to adhere to the treatment regimen properly and informed him that if adequate blood glucose control could not be established at the end of one month, he would have to insist on the use of insulin. |
| Manoj Kumar agreed and the doctor increased the dose of SU and metformin marginally and added another OHA with a different mechanism of action than the current drugs. Manoj Kumar started the new treatment regimen, increased his daily physical exercise level and reduced his daily caloric intake in order to attain the fasting and 2 h post- prandial glycemic targets advised by his doctor. |
| At the end of one month of the new regimen, Manoj Kumar’s blood glucose levels were 160 mg/dl (fasting) and 230 mg/dl (2 h post-prandial); which were obviously short to the target values. He also complained of weakness, fatigue, flatulence, headache, metallic taste in the mouth, and nocturia; and admitted to his doctor that he was worse-off than before. He agreed to try out insulin therapy in the hope that it would work. |
| His doctor prescribed the following treatment : |
| Inj Human Mixtard 12 iu every morning before breakfast
Inj Human Mixtard 8 iu every evening before supper Tab Metformin 500 mg after breakfast, lunch and dinner |
| On follow-up after 15 days the blood glucose levels were 110 mg/dl (fasting) and 230 mg/dl (2 h post-prandial). The nocturia had disappeared and Manoj Kumar felt a new strength in his limbs. His appetite improved and he was able to eat more. His weight increased by 1 kg. The benefit was maintained at the end of the first month and also at the end of 3 months of insulin therapy. He found insulin injection easy to take and virtually painless. He had also found out that several persons with type 2 diabetes do take insulin and most of them had reported no difficulty in injecting themselves. |
| Manoj Kumar agreed that many of his feelings regarding insulin therapy were based on unsubstantiated misconceptions, and agreed to continue the treatment advised by his physician because he found that he felt much better than before after starting insulin. He had understood that oral drugs have their limitations in controlling blood glucose and most of them fail to provide proper control after a few years of daily use. He also realised that insulin is the definitive replacement therapy for type 2 diabetes. He wished that he had taken his doctor’s advice earlier, but also admitted that he might not have perceived the benefits of insulin therapy if he had been forced to take insulin by the doctor. He appreciated his doctor’s concern for his state and was glad that the doctor had allowed him to realise the necessity of using insulin for good blood glucose control by allowing him to experiment with the results of withholding insulin. Once he started using insulin and his condition improved, Manoj Kumar’s fears regarding insulin evaporated quickly. |
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