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Clinical Scenario Mini Cases: DIABETES
Mini Case 1
Jamie West’s cousin is a 49 year old male with type 2 diabetes. He works 12 hour
shifts at Loblaws stocking shelves with shifts changing every 7 days. His last A1C was
7.8% and he is taking metformin 1000 mg po bid and glyburide 10 mg po bid. He eats
his largest meal between 11 PM – 12 AM and he often skips meals because he is
sleeping or he eats in the middle of the night. He receives benefits through work.
How would you manage this patient?
What changes to his medications would you make?
Write a complete prescription for this patient if applicable.
Primary Care Associates
123 Wellness Road, Anytown, Canada, (123) 456-7890
Name: ________________________ Date: ___________________________
Address: ______________________________________________________
Diabetes Module – Sept 2015
© 2015
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Mini Case 1
Issues:
1. Timing of oral hypoglycemics
2. Consideration for shift workers
Answer:

Consider when he takes his oral hypoglycemics and the resulting blood glucose
readings in relation to his work schedule. It may be helpful to adjust the time
when he takes the metformin and glyburide to correspond with largest meal i.e.
between 11 PM – 12 AM.

For some shift workers, some flexibility is required as work times may change
and meals/ food intake may be affected. Jamie’s cousin sometimes skips his
meals or eats at different times. In such circumstances, meglitinides or alpha
glucosidase inhibitors may offer benefit over sulfonylureas in terms of flexible
dosing when he eats (i.e. he doesn’t take it when not eating a full meal).

Can also consider DPP-4 inhibitors or SGLT-2 inhibitors as these are not
affected by meals or how a patient eats

Rx:
Stop glyburide
Repaglinide 0.5 mg po 30 minutes before meals M: 90 RX1
( May titrate dose up to normalize blood glucose and achieve A1C)
OR
Acarbose 50 mg Tab PO with first bite main meal M:90 Rx1
(may titrate up to 100mg tid)
Diabetes Module – Sept 2015
© 2015
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Mini Case 2
Charles is a 67 year old male with Type II DM x 10 years. He takes metformin 1000mg
po bid and glyburide 5mg po bid with glucose levels within target.
He was recently diagnosed with hypertension with BP values ranging from 140/85
mmHg to 160/95 mmHg. He was started on:
- Hydrochlorothiazide 12.5mg po daily
- Metoprolol 25mg po bid
Over the past week, Charles’ glucose readings are in the 15’s.
How would you manage this patient?
What changes to his medications would you make?
Write a complete prescription for this patient if applicable.
Primary Care Associates
123 Wellness Road, Anytown, Canada, (123) 456-7890
Name: ___________________________________ Date: _______________________
Address: ______________________________________________________________
Diabetes Module – Sept 2015
© 2015
4
Mini Case 2
Issues:
1. Compliance considerations
2. Drug-induced causes of hyperglycemia
Answer:

Ascertain if Charles is adjusting to his new medication regimen with the addition
of two new drugs. He may be having difficulty managing the timing of his meds or
missing some doses. There may be increased stress/worry with the new
diagnosis of hypertension and he might be “giving up”.

Hydrochlorothiazide: mild hyperglycemia has been reported in diabetics and nondiabetics following thiazide diuretic therapy

Metoprolol: beta blockers can cause hyperglycemia by beta-blocker inhibition of
insulin release. Beta 1 selective agents may have less of an effect on glucose
alteration (i.e. atenolol, bisoprolol, metoprolol, acebutolol)

Consider: ACE inhibitors which do not have effect on blood sugar and may be
beneficial for diabetic patients (i.e. cardiovascular and renoprotection).

Rx:
Stop HCTZ first, then metoprolol if sugars not good enough
Start Ramipril 5 mg po daily X 30 (or any other ACE)
Diabetes Module – Sept 2015
© 2015
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Mini Case 3
Tina is a 59 year old RN working at local hospital. Her last A1c was 0.072 and eGFR 30
(stable in past year)
Her medications include:
- Metformin 1000 mg bid
- Glyburide 5 mg bid
- ASA 81 mg OD
- Lipitor 20 mg OD
She is experiencing frequent lows, especially overnight.
How would you manage this patient?
What changes to her medications would you make?
Write a complete prescription for this patient if applicable.
Primary Care Associates
123 Wellness Road, Anytown, Canada, (123) 456-7890
Name: ______________________________ Date: ________________________
Address: __________________________________________________________
Diabetes Module – Sept 2015
© 2015
6
Mini Case 3
Issue:
1. Hypoglycemic agents in renal insufficiency
Answer:



Consider when Tina is taking her medications in relation to food intake (e.g.
when she works night shift).
In decreased renal dysfunction, glyburide and metformin may result in delayed
excretion and increased accumulation
Consider efficacy and safety of metformin in reduced eGFR
Options:
 Discontinue metformin
 Reduce glyburide dose to 2.5 mg po bid; Consider switch to gliclazide 40 mg po
bid or repaglinide 0.5 mg po tid ac
 Consider long acting insulin once daily such as insulin glargine or detemir.
 Linagliptin can be an option for consideration
Diabetes Module – Sept 2015
© 2015
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Mini Case 4
Paul is a 48 year old male with Type 2 DM x 6 years. He is obese with BMI 35. His A1C
is 0.078 and fasting glucose average 12.
His diabetes meds are:
- Metformin 1000 mg bid
- Diamicron MR (glicazide) 30 mg 4 tabs daily
- Actos (pioglitazone) 45 mg OD
You have decided to start bedtime insulin.
What regimen will you give?
Which medications do you stop? Which do you keep?
Write a complete prescription for this patient if applicable.
Primary Care Associates
123 Wellness Road, Anytown, Canada, (123) 456-7890
Name: ______________________________ Date: _______________
Address:________________________________________________
Diabetes Module – Sept 2015
© 2015
8
Mini Case 4
Issue:
1. Initiating insulin
Answer

Refer to slides for once daily insulin starts. Several basal insulins may be used at
bedtime for Type 2 diabetics. NPH insulin has traditionally been the choice at
starting doses of 5 to 10 units SC QHS although glargine or detemir may be
considered due to longer duration of action and ‘peak-less’ activity.


Consider if there is benefit in keeping sulfonylurea with insulin due to similar
mechanisms of action and potential for weight gain.
Which combinations with insulin have been studied? Metformin + insulin may
cause less weight gain than glyburide + insulin. This may be beneficial in our
gentleman.
Thiazolidinedione + insulin combination is not recommended in Canada.

Rx:

Initiate insulin glargine (or detemir or NPH) 10 units SC QHS. Titrate up by 1
unit every day until blood sugar 4-7 mmol/L M: 5 vials
M: corresponding insulin pen
Keep metformin 1000 mg po bid
Stop pioglitazone
Maintain gliclazide for now with aim to decrease/ discontinue while increasing
insulin


Ontario College of Family Physicians has developed tool which includes useful
tips for initiating and titrating insulin and writing prescription
http://ocfp.on.ca/docs/default-source/clinical-tools/insulin-titration--insulin-prescription-november-2014-v4.pdf?sfvrsn=2
Diabetes Module – Sept 2015
© 2015
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Mini Case 5
Jamie has a friend who is a type 1 diabetic for 5 years. He is on the following insulin
regimen:
 8AM: Humulin 30/70 30 units
 6PM: Humulin 30/70 20 units
His logbook fasting readings are as follows:
8 AM
6.9
6.7
5.3
12 PM
8.9
8.2
8.1
6 PM
11.5
12.6
13.2
10 PM
9.5
11.1
9.0
How would you manage this patient?
What changes to his medications would you make?
Write a complete prescription for this patient if applicable.
Primary Care Associates
123 Wellness Road, Anytown, Canada, (123) 456-7890
Name: ______________________________ Date: _______________
Address: ________________________________________________
Diabetes Module – Sept 2015
© 2015
10
Mini Case 5
Issue:
1. Matching insulin pharmacokinetics to daily activities
Answer:


Make sure that his glucometer is in working condition and has been checked
against the laboratory at least once yearly.
Consider if there is a trend in the readings. There are no outliers. 6 PM has
consistently highest readings. 10PM readings are also high.


Would target 6 PM readings first.
Morning NPH peaks around 6 PM therefore should increase this dose (bearing in
mind will increase Regular dose with premix 30/70 insulin). Could adjust Evening
dose but 10 PM values will likely also decrease after 6 PM normalizes.

Rx:
Increase 8AM Humulin 30/70 to 32 units (then 1 unit/day for slow
adjustment)
Diabetes Module – Sept 2015
© 2015
11
Mini Case 6
Jamie’s friend has now been switched to intensive insulin therapy. His dosage is:
 8AM, 12PM and 6PM: Novorapid 8 units
 10PM: Detemir 20 units
His logbook fasting readings are as follows:
8 AM
14.4
13.0
11.0
10.4
13.5
12 PM
6.5
8.0
7.9
7.0
6.8
6 PM
15.3
6.3
8.4
7.1
6.8
10 PM
7.8
11.2
10.8
12.8
5.3
How would you manage this patient?
What changes to his medications would you make?
Write a complete prescription for this patient if applicable.
Primary Care Associates
123 Wellness Road, Anytown, Canada, (123) 456-7890
Name: ______________________________ Date:_______________________
Address: _______________________________________________________
Diabetes Module – Sept 2015
© 2015
12
Mini Case 6
Issue:
1. Adjusting insulin therapy
Answer:




Examine the readings to determine if there is a trend. Exclude outliers such as:
6PM (15.3), 10PM (5.3)
Average BS: 8AM (12.5), 12PM (7.2), 6PM (7.2), 10PM (10.6)
8AM has highest readings consistently

Consider managing this patient by increase evening Detemir first to address AM
fasting highs by 1-3 units (1 unit/day for slow titration)
10PM readings are second highest
Could increase 6PM Novorapid but this peaks around 1-1.5 hours later only so
values may still be a little high at 10PM (increase by 1-2 units)
Consider decreasing size of 8-10PM snack

Rx:


Increase Detemir to 22 units SC at 10 PM
May increase by 2 units every 3 days until fasting AM sugars < 7
Diabetes Module – Sept 2015
© 2015