Quick Case Study

Overcoming Complex Barriers to Glycemic Control in Type 2 Diabetes

A 51-year-old woman with type 2 diabetes was referred to Duke Medicine’s Endocrinology, Metabolism, and Nutrition division by her primary care provider because her hemoglobin A1C (HbA1C) had been 14% for at least 2 years. In fact, her HbA1C had not been below 9% since 2010.

She received a diagnosis of type 2 diabetes at 30 years of age. Before her initial diagnosis, she had fainted while at work, and her blood glucose was found to be 456 mg/dL. At that time, insulin was initiated. At the time of referral to Duke Medicine, she was on a basal-bolus regimen established by her primary care provider, but reported difficulty adhering to the recommendation; her blood glucose was always above her goal. The patient’s BMI was 33.

Duke Medicine endocrinologist Leonor Corsino, MD, saw the patient for the first time in February 2014. In addition to type 2 diabetes, the patient had several diabetes-associated complications including stage 3 chronic kidney disease (CKD), gastroparesis, neuropathy (in both feet), hepatic steatosis, hypertension, and hyperlipidemia, for which she took multiple medications. She also had received a diagnosis of fibromyalgia and chronic pain. In addition, Corsino learned that the patient had bipolar affective disorder.

How would you approach this patient to help her better control her HbA1C levels?

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Answer: Acknowledge the role that her mental health issues may be playing and develop a regimen better suited to her individual circumstances.

“When you have a patient who has trouble achieving glycemic control, it’s critical to ask the patient about barriers to health care and to assess psychosocial factors,” Corsino said. She found that the main issues that were affecting the patient’s ability to control her diabetes appeared to be her chronic pain and bipolar disorder.

At the initial visit, Corsino acknowledged to the patient that her mental health may be playing a role in her poor glycemic control. “I told her she was not to blame for her inability to control her glucose, but at the same time explained that it was critical for her to improve her glycemic control to prevent her diabetes complications from worsening,” Corsino said. Although she felt that the patient’s primary care provider had prescribed a reasonable insulin regimen, Corsino slightly adjusted the insulin doses, prescribing 130 units of insulin glargine at bedtime and 40 units of rapid-acting insulin aspart at meals. Corsino had the patient use 2 injections of 65 units each for the insulin glargine since the dose was large and multiple doses are easier to inject than one single large dose. The patient was not prescribed any other antihyperglycemic medications, such as metformin, because of her diminished kidney function. However, to help her address her obesity, she was prescribed lorcaserin.

Corsino also immediately referred the patient to a diabetes educator. “Here at Duke, we have two types of diabetes education—group classes or individual sessions,” Corsino said. “For patients who have mental health issues that could interfere with their ability to understand information, I send them for individual sessions.” The diabetes educator discussed lifestyle modifications, hypoglycemia awareness, and blood glucose monitoring. The patient was instructed to limit her carbohydrate intake at each meal, eat 6 mini-meals per day to manage her gastroparesis, and not skip meals.

Corsino also felt that the patient’s diabetic neuropathy was contributing substantially to her chronic pain and interfering with her ability to focus on diabetes management. In the past, the patient had been prescribed pregabalin, duloxetine, and gabapentin for pain management without success, so Corsino also referred her for a neurology consult and contacted the patient’s mental health care provider to discuss her proposed goals for the patient, “to make sure we were on the same page,” Corsino explained.

Since February 2014, Corsino and staff have closely monitored the patient, seeing her for four follow-up visits—a step that Corsino considers crucial for success with patients who have complex needs. At her August 2014 visit, the patient’s HbA1C had decreased to 7.8%, the lowest value she had achieved since 2009. Her fasting and mealtime blood glucose levels were mostly at goal, and she had very few readings above 180 mg/dL after eating. Additionally, her BMI had decreased to 31.

“What made a difference for this person was acknowledging her mental health issues, referring her for diabetes education, and working with her other health care providers to give her a more personalized approach. We also kept her motivated by giving her positive reinforcement that she could do this,” Corsino said.

Corsino further stressed the importance of evaluating a patient’s psychosocial status at every visit and not just focusing on blood glucose values. She uses a template that includes specific questions about financial problems, family conflicts, and competing priorities to identify barriers.

Corsino realizes that implementing such an intensive approach isn’t always feasible in a busy primary care practice. “We’re here to help primary care providers, especially with this type of case where the patient has had no control for years and they are losing hope,” she concluded.