A routine physical examination is an obligatory step for every patient who takes care of his or her health. A primary care provider (PCP) performs all the necessary checks to understand the peculiarities of the condition and share recommendations if necessary. In this case study, R.P. is a 43-year-old woman with gestational diabetes as part of her past medical history and prediabetes, resolving each time after giving birth, is presented. This time, her vital signs are disturbing: blood pressure (BP) is 145/88 mmHg, obesity signs, and fasting plasma glucose level (FPG) is 119 mg/dL. The woman does not take any medications, alcohol, or tobacco products and denies polyuria, polyphagia, and polydipsia. The development of type 2 diabetes is evident, and the patient needs additional recommendations and effective therapy.
Patient History and Examination
Diabetes risk factors have to be thoroughly examined together with the patient’s history. In this case, the woman has already been diagnosed with gestational diabetes and experienced symptoms changes while giving birth. According to Deputy et al. (2018), for mothers, this type of diabetes increases the risk for future diabetes, and it is recommended to take some preventive steps before, during, and after pregnancy. However, the patient reported no medications being taken at the moment of an examination. Besides, her family history presents type 2 diabetes, cardiovascular diseases, and hypertension, which is also defined as a considerable risk for diabetes in the patient (Tobias et al., 2017). Finally, Babu et al. (2018) report the association of obesity, hypertension, and diabetes in adult populations. R.P. is obese, and her BP level is high, which proves the development of type 2 diabetes.
Additional Information for Treatment
In most cases, the diagnosis of diabetes is not easy to make, regarding the presenting symptoms of weight loss, polyuria, polydipsia, and polyphagia. However, R.P. denies all these symptoms, and the only problems are her obesity, high BP, and the increased FPG level. If FPG is between 100-125 mg/dL (less than 7 mmol/L), prediabetes is defined (Lim et al., 2018). Therefore, additional information like the evaluation of the glycated hemoglobin (Hb) A1C is required. Compared to FPG that is a simple blood glucose test in a patient who does not take calories for the last eight hours, HbA1C is a long-exposure test that estimates the average blood glucose level.
Goals of Therapy and Biochemical Indices
The results of additional tests prove that R.P. has diabetes. Her A1C is about 8.2%, which significantly increases the normal level of 5-6% (Lim et al., 2018). Therefore, the initial goal of her treatment should include the maintenance of the blood sugar level and the prevention of tissue damage due to increased sugar in the blood (Aschner, 2017). At the same time, diabetes therapy has to be directed to manage the patient’s weight and reduce the body mass index (Aschner, 2017). When therapy goals and treatment methods are defined, certain biochemical indices have to be monitored. Attention must be paid to glucose, glycated hemoglobin, triglycerides, lipoproteins, cholesterol, and peptides (Laakso, 2019). The elevation of one biomarker provokes changes in another index, which results in carbohydrate and lipid metabolism disorders.
The initial management recommendations occur when the A1C is elevated, and the case of R.P. is the one when pharmacologic therapy and lifestyle modifications (diet and physical exercises) are required. For a long period, insulin was the only effective method to treat diabetes; now, people get access to sulfonylureas and metformin, which the first-line agent for diabetic patients to control insulin resistance (Aschner, 2017). Despite the existing variety of treatment methods, a common dosage of metformin is 500 mg twice daily, with the prospect of increasing by 500 mg every second week (Baker et al., 2021). It is expected that the patient reaches the necessary tolerated dose and avoids the growth of adverse gastrointestinal effects or lactic acidosis (Baker et al., 2021). If no intolerance of metformin or vitamin deficiency is observed, R.P. can be on the same medication long term.
Adjustments to Therapy
For a certain period of time, R.P. has been taken metformin 1000 mg twice a day, and she returns to the clinic for her next follow-up visit. Her A1C level is decreased up to 7.8%, which means that metformin works effectively. It is high time to adjust the patient’s therapy and think about second-line drugs like sulfonylureas, pioglitazone, and other inhibitors (Aschner, 2017). The decision to take glimepiride (second-generation sulfonylureas) as an appropriate anti-diabetic agent is made. The purpose of the next step for pharmacologic treatment is to make sure that weight gain is not a problem for the patient. The combination of metformin and sulfonylurea must be suitable for R.P.
Pieces of Advice and Procedures
After three months of the properly chosen therapy, R.P. returns and asks about the possibility of changing her treatment plan and replacing her current drugs with an injectable medication advertised on TV. She believes that this alternative would help her lose weight and wants to hear if she is a good candidate. Following the rules of professional ethics, a therapist must evaluate the current condition of the patient, which reveals that R.P. meets all the criteria for injectable medications. However, it is recommended to inform her that many drug advertisements underline some positive effects to attract people’s attention and neglect the adverse effects and possible complications. R.P. is free to make her decision, and the task of a therapist is to give all information and precautions.
Treatment Regime Modifications
In one year after taking the chosen injectable medication and oral anti-diabetic agents, the patient reports a tingly sensation to both feet, and her A1C lab result is 10.2% (considerably increased). In addition, she has hyperlipidemia and chronic kidney disease, meaning that her diabetes is out of control. Insulin therapy is the only regime that may help the patient. Basal insulin is one of the most convenient initial insulin regimens to reduce the level of hyperglycemic in combination with metformin and another non-insulin agent (Baker et al., 2021). Finally, it is important to stop using other injectable medications and make sure that the A1C level is managed and does not threaten her life.
Type 2 diabetes is never a simple disease that may be treated one day. People should be ready to live with this condition and remember crucial lifestyle modifications and pharmacologic therapy. Therapists are ready to examine their patients and offer the best medical options. However, the challenges to effective drug therapy, like the impact of media or personal preferences, cannot be ignored. The example of R.P. shows that diabetes management is not a one-step decision but a well-developed plan with first- and second-line treatments. Metformin, sulfonylureas, and insulin remain the most effective medicines for diabetic patients to control their glucose levels in the blood and predict the growth of health complications.
Aschner, P. (2017). Recent advances in understanding/managing type 2 diabetes mellitus. F1000Research, 6. Web.
Babu, G. R., Murthy, G. V. S., Ana, Y., Patel, P., Deepa, R., Neelon, S. E. B., Kinra, S., & Reddy, K. S. (2018). Association of obesity with hypertension and type 2 diabetes mellitus in India: A meta-analysis of observational studies. World Journal of Diabetes, 9(1), 40-52. Web.
Baker, C., Retzik-Stahr, C., Singh, V., Plomondon, R., Anderson, V., & Rasouli, N. (2021). Should metformin remain the first-line therapy for treatment of type 2 diabetes? Therapeutic Advances in Endocrinology and Metabolism, 12. Web.
Deputy, N. P., Kim, S. Y., Conrey, E. J., & Bullard, K. M. (2018). Prevalence and changes in preexisting diabetes and gestational diabetes among women who had a live birth – United States, 2012–2016. Morbidity and Mortality Weekly Report, 67(43), 1201-1207.
Laakso, M. (2019). Biomarkers for type 2 diabetes. Molecular Metabolism, 27, 139–146.
Lim, W. Y., Ma, S., Heng, D., Tai, E. S., Khoo, C. M., & Loh, T. P. (2018). Screening for diabetes with HbA1c: Test performance of HbA1c compared to fasting plasma glucose among Chinese, Malay and Indian community residents in Singapore. Scientific Reports, 8(1). Web.
Tobias, D. K., Stuart, J. J., Li, S., Chavarro, J., Rimm, E. B., Rich-Edwards, J., Hu, F. B., Manson, J. E., & Zhang, C. (2017). Association of history of gestational diabetes with long-term cardiovascular disease risk in a large prospective cohort of US women. JAMA Internal Medicine, 177(12), 1735-1742. Web.