A 45-year-old man comes to the office for follow-up. He was diagnosed with diabetes mellitus 5 years ago and has had good control during most of that time on a program of long-acting and sliding-scale short-acting insulin analogues. However, the patient was admitted to the hospital 6 months ago for a hypoglycemic seizure, and his home glucose readings have been over 200 mg/dL frequently since. Medical history is notable for chronic pancreatitis related to excessive alcohol use. Vital signs and physical examination are normal. Hemoglobin A1c is 8.6%; a year ago, it was 7.2%. When the physician asks about the reasons for the change in glycemic control, the patient says, "I'm not sure, doctor. I feel pretty good right now." Which of the following is the most appropriate statement for initiating a discussion with this patient?

Question

A 45-year-old man comes to the office for follow-up.  He was diagnosed with diabetes mellitus 5 years ago and has had good control during most of that time on a program of long-acting and sliding-scale short-acting insulin analogues.  However, the patient was admitted to the hospital 6 months ago for a hypoglycemic seizure, and his home glucose readings have been over 200 mg/dL frequently since.  Medical history is notable for chronic pancreatitis related to excessive alcohol use.  Vital signs and physical examination are normal.  Hemoglobin A1c is 8.6%; a year ago, it was 7.2%.  When the physician asks about the reasons for the change in glycemic control, the patient says, "I'm not sure, doctor.  I feel pretty good right now."  Which of the following is the most appropriate statement for initiating a discussion with this patient?

Quizplus · Accepted Answer

11ec25c8_d2df_291a_bc81_e30811048905_MD0003_00 This patient had good glycemic control on a multidose insulin regimen but experienced loss of control after a severe episode of hypoglycemia. Patients with a diminished glucagon response, such as those with pancreatogenic diabetes (eg, chronic pancreatitis with fibrosis of the islets), can develop rapid and severe hypoglycemia with little warning. Such episodes can lead to confusion, seizure, and loss of consciousness and can be fatal. Even mild hypoglycemia can be distressing due to the associated autonomic activation, which can induce anxiety, tremor, palpitations, and sweating. Frequent or severe hypoglycemia can encourage behavioral changes to prevent recurrence, such as increased caloric intake, leading to weight gain, or reduced adherence to insulin management. In light of this, it helps to ask patients in a nonjudgmental manner about behavioral changes (eg, reducing insulin dose) they might be making to avoid hypoglycemia. Management strategies include less-stringent glycemic targets, flexible insulin regimens, and prescription of emergency glucagon kits. (Choice A) Although heavy alcohol use can impair glycemic control, there are no other indicators of current alcohol intake in this patient, and the time course suggests overcompensation for hypoglycemia as the primary cause. Once the behavioral factors that can affect diabetes control are addressed, discussions regarding continuing care for alcohol use disorder could be considered, if appropriate. (Choice B) Although this patient's home readings and hemoglobin A1c suggest that tighter glycemic control is desirable, the reasons for loss of control should be better understood before any changes are made to his insulin regimen. (Choice D) The patient reports no anxiety or mood symptoms to warrant referral to a mental health professional. The physician should first attempt to understand the patient's reasons for loss of glycemic control and consider changes in diabetic management before making a referral to another provider. (Choice E) Insulin therapy can be cumbersome and painful to administer, leading to nonadherence. However, this patient's loss of control dates to his hospital stay for hypoglycemia. Educational objective: Severe hypoglycemia can cause confusion, seizure, loss of consciousness, and death. Even mild hypoglycemia can be distressing due to the associated autonomic activation (eg, anxiety, palpitations, sweating). Frequent or severe hypoglycemia can encourage behavioral changes to prevent recurrence, such as increased caloric intake or less rigorous insulin management, which may impair glycemic control. References: Fear of hypoglycemia: relationship to physical and psychological symptoms in patients with insulin-dependent diabetes mellitus. (http://www.ncbi.nlm.nih.gov/pubmed/1582382) Fear of hypoglycemia in adults with type 1 diabetes: impact of therapeutic advances and strategies for prevention-a review. (http://www.ncbi.nlm.nih.gov/pubmed/26439754)

A 45-Year-Old Man Comes to the Office for Follow-Up