Type 2 diabetes management in a post-bariatric surgery patient

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A patient, aged 57 years, was admitted to the hospital to undergo gastric bypass surgery. He had a history of type 2 diabetes for ten years.

Diabetes management in a pre-, post-bariatric surgery patient
Diabetes management in a pre-, post-bariatric surgery patient

A patient, aged 57 years, was admitted to the hospital to undergo gastric bypass surgery. He had a history of type 2 diabetes for ten years.

Pre-admission diabetes therapy included metformin 1000 mg at morning and bedtime, insulin glargine (Lantus) 70 units every day in the afternoon or evening, insulin aspart (NovoLog) 30 units plus sliding scale three times per day.

The day prior to surgery, the patient reported taking metformin 1000 mg, insulin glargine 70 units, and insulin aspart 30 units with his evening meal. His hemoglobin A1c value was 8%, and it was taken just prior to surgery. The patient's blood glucose value on admission was 204 mg/dL.

Throughout the surgery, blood glucose values ranged from 208 to 214 mg/dL. Throughout the day, the patient received a total of 8 units of insulin aspart in correction doses for noted hyperglycemia.

The patient was instructed to take nothing by mouth on the day of surgery, and then was advised to start a bariatric clear liquid diet on post-operative day one, advancing as tolerated. This meal plan consisted of six small, liquid meals provided throughout the day with the goal of staying hydrated.

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On post-operative day two, blood glucose values ranged from 90 to 103 mg/dL. The patient continued to tolerate six small meals per day via a bariatric surgery diet. He was approved to dismiss from the hospital on post-operative day two. The patient was recommended to take a multivitamin with minerals daily after dismissal.

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Following surgery, the patient followed-up with his outpatient provider. He followed a bariatric diet in an effort to lose weight. Blood glucose values continued to range 80 to 90 mg/dL throughout the day throughout the first six months following surgery.

In the first six months following surgery, the patient lost 30 pounds. During outpatient follow-up, patient stated that his diabetes was resolved. His outpatient provider discussed with him that although his diabetes was considered diet controlled, if weight was re-gained following surgery, and the patient did not continue to follow a healthy diet, there was potential for blood glucose values to rise, requiring initiation of diabetes therapy in the future.

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Question 1: What would be appropriate diabetes management for this patient on the evening following surgery?

Correct answer: B.

Metformin was held during hospital stay. Insulin aspart was used to correct hyperglycemia post-operatively. The effect of bariatric surgery on blood glucose control in patients with diabetes can be dramatic. Therefore, there is a need to adjust antidiabetic drug dosages in the post-operative period in order to prevent hypoglycemia.

Despite the need for correction doses of short-acting insulin during the day due to noted hyperglycemia, the patient was given a reduced dose of insulin glargine, 35 units, was prescribed on the evening following surgery. The next day, blood glucose values ranged from 120 to 144 mg/dL.

Metformin continued to be held. The patient advanced his diet to a bariatric full liquid diet and was able to eat six small meals throughout the day. The insulin aspart correction scale was continued to correct any hyperglycemia. Insulin glargine, 10 units, was prescribed in the evening.

Question 2: What are appropriate diabetes related dismissal recommendations for this patient?

Correct answers: E.): Both C and D.

Metformin, insulin glargine, and aspart insulin were held. The patient was recommended to check blood glucose values twice daily in the morning and the afternoon, continue with his bariatric diet, and follow-up with outpatient provider seven to 10 days after discharge for ongoing blood glucose management.

Vomiting often occurs during the first few months following bariatric surgery due to overeating or chewing food inadequately.

Question 3: What are some common problems that are important to assess for in patients following bariatric surgery?

Correct answer: All of the above.

Dumping syndrome is a common experience following consumption of foods high in sugar. These foods bypass much of the stomach undigested and cause an osmotic overload upon entering the small intestine. This overload brings fluid into the lumen of the small intestine, resulting in a vagal reaction. Patients will often report feelings of lightheadedness and sweating after eating a high-glucose meal or drinking fluid with a meal.

To prevent vitamin deficiency, a multivitamin with minerals is commonly recommended in patients who undergo bariatric surgery. Vitamin B12 and iron deficiency are two of the most common problems and often do not respond to typical multivitamin supplementation.

A form of bone demineralization and secondary hyperparathyroidism has been reported in patients who have had gastric bypass surgery. One year following bariatric surgery, the patient followed-up with his primary-care provider. He had lost a total of 60 pounds since the surgery.

The patient reported following a healthy diet and exercising daily. The patient's ferritin level was found to be low at 8 ng/mL, with a hemoglobin of 11 g/dL. His vitamin D level was also low at 15 ng/mL. Knowing that patients require more aggressive treatment to correct vitamin deficiencies, the patient was recommended to take 50,000 IU of vitamin D once daily for five days, then monthly for three months.

After supplementation, the patient's vitamin D levels would be rechecked. For his low ferritin, a one-time iron infusion, elemental iron (Feraheme) 510 mg was administered intravenously. After the infusion, the patient was recommended to take iron supplements daily.

He was instructed to take the supplements at a different time from his multivitamin with minerals that contained calcium to enhance absorption. The patient's CBC and ferritin levels will be checked three months following the iron infusion.

Jennifer A. Grenell, APRN, CNP, practices at the Mayo Clinic department of Endocrinology, specializing in diabetes management.
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