Case study

Andreas Fernandez

Case 1
Male 55-year-old patient, came to the clinic
complaining weight loss for the past 8 weeks
although he has not lost his appetite. He also
complained lethargic during working hours, and
always feeling thirsty. At night, he woke up 3-4
times just to urinate. Now his weight is 70 kg,
and his height is 170 cm. He works in a bank,
with sedentary lifestyle. He has a diabetic
mother, and his father died 5 years ago because
of heart attack at the age of 55. He has never
done a medical check up for the last 5 years.

questions
What laboratory tests would you
suggest to diagnosed this
patient?
What is the diagnostic criteria of
diabetes mellitus?
What would your initial
rekommandations be for his
treatment?

Faktor pencetus
Kurang gerak
Makan berlebihan
Kehamilan
Kekurangan
produksi hormon
insulin
Penyakit hormon
yang kerjanya
berlawanan dgn
insulin

Gejala dan tanda

Berat badan
menurun
Banyak kencing
Banyak minum
Banyak makan
Kesemutan
Gangguan
penglihatan
Gangguan ereksi
keputihan

Kriteria diagnosis

Diagnosis diabetes

Gula darah
2 jam pp

Gula darah
puasa

Case 2
Mr. P is a 56 year old man, weight 68 kg and height 165
cm, waist 94 cm. BMI 28, smokes 24 cigarettes a day
and doesnt work anymore. He had a history of MCI, 1
year ago and is treated with a statin, captopril,
bisoprolol and aspirin. His hearts pump function is
normal.
He was diagnosed with type 2 diabetes since 1 year
ago. He eats 1 large meal per day, and likes to eat
snacks in between his meals. He exercises 10 minutes 4
times a week. He is on Metformin 500 mg three times
daily. He has microalbuminuria with normal creatinine.
He came to your clinic with BP 150/85 mmHg, FBG 165
mg/dl, PPBG 254 mg/dl. and HbA1c 8.0 %.

questions
Would you suggest him to
change his lifestyle? If you
would, what would be your
advice for him?
Would you give him dietary
advice and if so what would you
emphasis?

Terapi gizi medis

lemak

protein

Kebutuhan kalori

Faktor koreksi

Latihan jasmani

Aktifitas fisik

Case 3
54 year old male lawyer has had high blood glucose for over
a year, but only now after a random reading exceeds 300
mg/dL on an office visit is he willing to admit that he has
diabetes.He has had a previous heart attack and is taking
several cardiovascular and hypertensive medications. His
blood pressure and physical exam today are normal. He has
a BMI of 28. He admits to feeling a little tired, recently, and
has been getting up at night to urinate at least two to three
times per week. His last A1C: 9.5%
Cholesterol Total:153 mg/dL LDL:70 mg/dL HDL:41 mg/dL
Triglycerides: 225 mg/dL Creatinine:0.8 mg/dL
Microalbuminuria:negative.
Currently, he is taking HCTZ, 25 mg qd Metoprolol 50 mg
qd, Aspirin 80 mg qd, Simvastatin 20 mg qd

questions
How would you initially treat this
patient?
How would you titrate dose?
What HbA1c would you target
for?

21

Healthy eating, weight control, increased physical activity & diabetes education

Monotherapy

Metformin

Efcacy*
Hypo risk
Weight
Side effects
Costs

Me ormin
intoleranceor
contraindica on
Dual
therapy

HbA1c
9%

Efcacy*
Hypo risk
Weight
Side effects
Costs

high
low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):

Metformin

Metformin

Sulfonylurea

Thiazolidinedione

DPP-4
inhibitor

high
moderate risk
gain
hypoglycemia
low

high
low risk
gain
edema, HF, fxs
low

intermediate
low risk
neutral
rare
high

Metformin

Metformin

Metformin

Metformin

SGLT2
inhibitor

GLP-1 receptor
agonist

Insulin (basal)

intermediate
low risk
loss
GU, dehydration
high

high
low risk
loss
GI
high

highest
high risk
gain
hypoglycemia
variable

If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):

Metformin

Triple
therapy

Sulfonylurea

+
TZD

Uncontrolled
hyperglycemia

(catabolicfeatures,
BG300-350mg/dl,
HbA1c10-12%)

Metformin

Thiazolidinedione

SU

Metformin

Metformin

DPP-4
Inhibitor

SGLT-2
Inhibitor

SU

SU

Metformin

GLP-1 receptor
agonist

Metformin

Insulin (basal)

+
TZD

SU

or

DPP-4-i

or

DPP-4-i

or

TZD

or

TZD

or

TZD

or

DPP-4-i

or

SGLT2-i

or

SGLT2-i

or

SGLT2-i

or

DPP-4-i

or

Insulin

or

SGLT2-i

or

Insulin

or

Insulin

or GLP-1-RA

or GLP-1-RA

or

or

Insulin

or GLP-1-RA

Insulin

If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:

Metformin

Combination
injectable
therapy

Basal Insulin +

Mealtime Insulin or

GLP-1-RA

Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0

Sasaran Pengendalian DM
Parameter

Sasaran

BMI (kg/m2)

18,5 - < 23 *

TDS (mmHg)

< 140

TDD (mmHg)

< 90

GD pre-prandial
kapiler

80-130 **

GD 2 jam PP
kapiler

< 180 **

A1c (%)

< 7 (atau individual)

Kolesterol LDL
(mg/dl)

< 100 (< 70 bila risiko KV

sangat tinggi)

Kolesterol HDL
(mg/dl)

Pria > 40, wanita > 50

Trigliserida (mg/dl)

< 150

*The Asia Pacific Redefining Obesity and Its Treatment 2000

** Standards of Medical Care in Diabetes, ADA 2015

Case 4
A 55-year old woman was diagnosed with T2DM, she was
initiated on metformin (500 mg b.i.d.) and, because she was
obese, advised her to lose weight through specific dietary
changes and a commitment to a regular walking program of 30
minutes per day.Since then you have seen her twice (every six
months) and have increased her dosage each time because her
HbA1c has remained above 7.0%. For the past six months, she
has been on a maximally effective dose of metformin (1,000 mg
b.i.d.).
The patients HbA1c is 7.6%, which is an increase from 7.2% six
months ago, and her fasting blood glucose level was 163 mg/dl
and ranges between 150 and 170 mg/dl.Her LDL, HDL, and
triglycerides are in target range.Additional lab tests show
normal results for thyroid, renal and liver function. Her blood
pressure is 130/80 mmHg, her BMI is 31 kg/m2.

questions
What would be the most
appropriate treatment for this
patient?
What would be your target
HbA1c ?

Case 5
67 years old male with T2DM for 10 years. His
father died of MI at an early age. He has
microalbuminuria and loss of sensation in both
feet. He is overweight BMI 27 kg/m2, HbA1c 7.2
% and BP 145/75 mmHg. He is treated with
pioglitazone 10 mg daily and metformin 1000
mg BID, Lisinopril 5 mg and Simvastatin 40 mg.
He comes to you and complains of fatique and
shortness of breath when walking fast. He has
also noticed that his legs have started swelling
during the day. He has not experienced pain.

 What diagnostic considerations

do you have?
Will you consider revising his
medication?

Risk & Benefit Characteristic of Glucose Lowering Agents

Class

Advantages

Disadvantages

Biguanide Extensive experience, no

s
hypoglycaemia, CVD
events (UKPDS)

GIT side effects, lactic

acidosis risk (rare),
Vitamin B12 def, multiple
contraindications: CKD,
acidosis, hypoxia,
dehydration, etc

SUs

Hypoglycaemia, weight
gain, low durability

Extensive experience,
microvascular risk
(UKPDS)

Meglitinid Postprandial glucose

es
excursions, dosing
(glinide) flexibility

Hypoglycaemia, weight
gain, frequent dosing
schedule

TZDs

Weight gain, oedema /

heart failure, bone
fractures

No hypoglycaemia,
Durability, HDL-C,
triacylglycerols
ADA Standards of Medical (pioglitazone)
Care 2015

Risk & Benefit Characteristic of Glucose Lowering Agents

Class

Advantages

Disadvantages

Glucosidase
inhibitors

No hypoglycaemia, nonsystemic

GIT side effects, frequent

dosing schedule

DPP-4
inhibitors

No hypoglycaemia

Angioedema/urticaria and
other immune-mediated
dermatological effects

Insulins

Universally effective,
theoretically unlimited
efficacy, microvascular
risk (UKPDS)

Hypoglycaemia, weight
gain, injectable, training
requirements, Stigma
(for patients)

GLP-1
receptor
agonists

No hypoglycaemia, weight
reduction

GIT side effects, C cell

hyperplasia/ medullary
thyroid tumours in
animals, injectable,
training requirements

ADA Standards of Medical Care 2015

Case Study
Mr. S, 54 year-old came to your clinic
with increase frequency of urination at
night. He also complained of tingling
sensation in both feet. His mother had
diabetes and already died from
myocardial infarction. His father also had
diabetes and died from ESRD. He looked
very afraid of diabetic complications
His FBG was 180 mg/dL, PPBG 290
mg/dL

Questions
What is the problems of this patient?
When and how would you do
evaluation for diabetic
complications?
How would you manage this patient?