Intervention

The patient has uncontrolled type 2 diabetes despite recent antihyperglycemic medication titration. Her vital signs are within targeted range. She has class I obesity, leads a relatively active lifestyle, and does not observe a diabetic diet. She would benefit from the addition of an antihyperglycemic agent with a weight-loss benefit, such as a GLP-1 agonist (liraglutide, exenatide).

For further evaluation, the following labs should be ordered: lipid panel to evaluate antihyperlipidemic therapy, comprehensive metabolic panel to evaluate renal function, electrolyte balance and possible contraindications for metformin therapy, and thyroid stimulating hormone (TSH) to evaluate thyroid function in relationship to obesity/low energy level. However, insufficient sleep is more likely the cause of her fatigue.


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She does exhibit some social/lifestyle risk taking behaviors and would benefit from diabetes-related lifestyle counseling, fertility-related counseling, and electronic resources. 

Outcome

All lab results came back normal. During a 1-month follow-up, the patient lost 2 lbs and reported a decrease in appetite after continuing on once-weekly exenatide. She has not been able to adjust her sleep schedule to decrease morning fatigue, but the patient will continue to try to get more sleep.

Discussion

While there are specific guidelines for diabetes management in children, adolescents, and the elderly, there are limited resources on the needs of the younger adult population with diabetes. According to the CDC, 4.1% of people with diagnosed diabetes are between the ages 20 and 44, representing 4.3 million individuals. The rate of new cases is 3.4 per 1,000 in this population.1 Younger adult patients with diabetes can have very different healthcare needs compared with the elderly patient that clinicians are more accustomed to managing. 

Early adulthood is complicated by competing educational, social, and economic needs; avoidance of responsibility; sense of invincibility; and resistance to “adult” control or advice. The demands of diabetes self-care added to this typically complex development stage can easily become overwhelming. It is not until late adulthood that independence in decision making, beliefs, values, and finances along with ownership of one’s responsibility are established.2 In later adulthood, these individuals often have to create and care for a family while balancing a career.

During this time it can become very challenging for patients to devote time and attention to their diabetes self-management needs. A survey of young adults with type 1 diabetes has indicated that they have different expectations from clinical visits compared with other diabetes patients. Typical diabetes topics such as carbohydrate counting, intensive insulin therapy, and sick day management were rated lower in terms of priority in contrast to goal setting, stress management, innovative diabetes research, sex/pregnancy, finances, alcohol, and drugs.2

The rate of substance abuse for young adults with type 1 diabetes ranges from 10% to 20% and is likely underreported. Use of cocaine and amphetamines can lead to sympathetic overactivity; ecstasy can result in hyponatremia; and marijuana can induce excessive carbohydrate intake and has been linked to development of ketoacidosis.2 Alcohol intoxication can cause hypoglycemia that lasts up to 24 hours. The CNS relies mainly on glucose for energy, so persistent hypoglycemia can lead to permanent brain damage and death.3 Young adults with comorbid substance abuse and type 2 diabetes share similar complications with their type 1 counterparts.

Cigarette smoking and nicotine addiction often begin in adolescence and young adulthood. One in three young adults younger than age 26 years smoke, and approximately three out of four will continue to smoke into adulthood. For those who continue to smoke, one-third will have life spans approximately 13 years shorter than their nonsmoking peers.4 Smokers with diabetes have an equivalent to increased risk for cardiovascular disease, premature death, and microvascular complications of diabetes.

Regardless of whether a patient smokes, routine counseling about the harm of smoking should be part of diabetes care. Providers should note that the recent trend of using e-cigarettes is not more beneficial compared with cigarette smoking and does not result in cigarette smoking cessation.5