Getting hemoglobin A1c under control after a relapse

A patient with diabetes questions the necessity of starting a statin.

A patient, aged 57 years, was diagnosed with type 2 diabetes 5 years ago when her blood sugar was found to be elevated at 300 mg/dL, with a hemoglobin A1c of 8.9%. She experienced extreme fatigue at that time. She was started on metformin, along with recommendations for diet, exercise, and weight loss.

One year later with the addition of metformin and titration up to 1000 mg twice daily, as well as improved diet, exercise, and a 10% weight loss, her hemoglobin A1c (HbA1c) improved to 7.7%. With this elevation in HbA1c, it was recommended that she take glipizide 5 mg once daily in addition to metformin. It was also suggested that her blood glucose values be metered 2 to 3 times weekly at alternating times. Glipizide was later increased to 5 mg twice daily to improve control.

Nine months ago, she was hospitalized for right knee surgery. Just prior to this admission, she stated that she had decided to stop taking glipizide and was continuing to work on eating a healthy diet. She denied hypoglycemia or other adverse effects on glipizide, and stated that she simply no longer wanted to take the medication. She was not currently exercising due to knee pain. Her HbA1c was found to be elevated at 7.4%.

At time of discharge, it was recommended she continue with dietary modifications, exercise as tolerated, and resume glipizide 5 mg once daily, It was also recommended that she continue with metering blood glucose values 2 to 3 times weekly at alternating times, and take metformin again in an effort to improve control.

She was seen 3 months later as an outpatient, and her HbA1c had improved to 6.7%. She admitted that she was taking metformin but had again stopped the glipizide, as she preferred to manage her diabetes with as few medications as possible. She denied issues with hypoglycemia and other adverse effects while on glipizide.

The patient was exercising, watching her diet, and had been successful at losing 5 pounds since her knee surgery. She was praised for her efforts, and was recommended to continue with metformin, dietary modifications, and exercise as tolerated. She also met with a dietician to review nutrition recommendations for ongoing diabetes management and weight loss.

Six months later, she returned as an outpatient for ongoing diabetes management. Unfortunately, she experienced a recurrence of knee pain, for which she is being evaluated for possible additional orthopedic surgery. She has not been able to exercise for the last several months, has experienced a recent 10-pound weight gain, and has not continued with previous nutrition recommendations for eating 3 meals per day with consistent carbohydrate content at each meal.

The patient has continued on metformin only and has stopped all glucose metering. She denied any gastrointestinal adverse effects on metformin. Her HbA1c is now elevated at 8.1%.

Diabetic review of systems

The patient's last eye exam was conducted 6 months ago, and she has no history of retinopathy. She is currently recommended for annual dilated eye exams.

She is taking a daily aspirin. She is on lisinopril 5 mg daily for renal protection and hypertension, and her current blood pressure is 114/70.

The patient saw her primary care provider 2 weeks ago and was instructed to start a statin —atorvastatin. She has not begun taking this medication and is inquiring as to whether or not she should begin. Her most recent cholesterol panel was as follows: total cholesterol: 194, triglycerides: 73, HDL: 64, and LDL: 115.

She denied any issues with peripheral neuropathy. The patient has a history of obstructive sleep apnea, and reported 100% compliance with wearing her continuous positive airway pressure machine nightly. She said she obtains twice-yearly dental exams.

Current creatinine is 0.7 with an estimated glomerular filtration rate of greater than 60. Her microalbumin is currently less than 5 with an albumin-creatinine ratio of less than 7.Her weight is currently 245 lbs up from the previous value of 232 lbs at last visit; her body mass index is 43.

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