CASE STUDY: UNCONTROLLED TYPE 2

DIABETES

MOHAMMAD NASIM
MBBS,FRSH(UK)
FELLOWSHIP IN ENDOCRINOLOGY ,DIABETES
AND METABOLISM
POSTGRADUATE DIPLOMA IN FAMILY MEDICINE
S E N I O R G P C O N S U LTAN T / FAM I LY P H Y S I C I A N
BADRUDDIN MEDICAL GROUP
JEDDAH,KSA

CASE STUDY
A 45-year-old woman with type 2 diabetes arrives for a
follow-up visit . She has been compliant with metformin
1000 mg twice daily. She reports that her home blood
sugar readings have improved slightly but are still high.
She admits to a few dietary indiscretions, such as having
multiple servings of dessert when going out with friends.
For exercise, she has been walking 10 to 15 minutes a
day.

CASE STUDY
She denies polyuria, polydipsia, or blurry vision. The
review of systems is unremarkable.

MEDICAL HISTORY
Her medical history is significant for:
Type 2 diabetes, diagnosed 6 months ago when she
presented with polyuria, blurry vision, and a random
glucose level of 276 mg/dl. Her HbA1c at that time was
9.0%.
She was started on metformin 500 mg twice daily, and
within 3 months her HbA1c dropped to 8.3%. The
metformin was increased to 1000 mg twice daily at that
time. She has not had significant hypoglycemic
episodes.

TREATMENT HISTORY
Hypertension, treated with PERINDOPRIL 5mg daily.
Dyslipidemia, treated with atorvastatin 20 mg daily.
Esophageal reflux treated with omeprazole 20 mg daily.

EXAMINATION
Vital signs are :
Blood pressure 122/76 mm Hg, heart rate 82, respiratory
rate 16, temperature 98.0 F,
Height 55, weight 73 kg, and BMI 26.0. She has not
gained or lost significant weight since she started
treatment for diabetes.

EXAMINATION
On exam:
The lungs are clear to auscultation, the heart has a
regular rate and rhythm without murmurs, and the
abdomen is non tender.
Peripheral pulses are normal, and there is no lower
extremity edema. The foot exam shows normal
sensation to light touch and no skin or toenail lesions.

LAB FINDINGS
HbA1c level, determined last week, is 7.8%.
Patients blood glucose log shows morning fasting
glucose ranging from 120 mg/dl to 150 mg/dl, and
postprandial readings at 190 mg/dl to 220 mg/dl.

TARGETS OF DIABETES CONTROL

The American Diabetes Association (ADA) recommends :
Target HbA1c of less than 7.0%, fasting glucose less than 130 mg/dl,
and postprandial glucose less than 180 mg/dl for most patients.1
A more ambitious HbA1c target of 6.0% to 6.5% may be appropriate
for patients with a long life expectancy and no cardiovascular
disease, provided that this can be achieved without adverse effects,
such as severe hypoglycemia.
On the other hand, a target HbA1c of 7.5% to 8.0% may be suitable
for patients with significant comorbidities, limited life expectancy,
and a history of severe hypoglycemia. This goal is also reasonable
for patients who have not been able to reach lower HbA1c levels with
multiple diabetes medications and extensive education about
diabetes self-management.
Given our patients overall health profile, her target is an HbA1c level
of less than 7.0%, or eventually even 6.0% to 6.5%.

ASSESSMENT
The patients HbA1c has improved since starting metformin,
but is still not at target. Her fasting and postprandial glucose
levels are also too high. The underlying causes for
hyperglycemia in this patient include dietary factors,
inadequate exercise, and obesity. She has no signs or
symptoms of an acute illness that could cause
hyperglycemia.
The maximum recommended dose of metformin for adults is
2000 to 2500 mg daily, depending on the formulation. Her
current total daily dose is 2000 mg, and it is unlikely that her
glycemic control will improve significantly just by adding
another 500 mg of metformin.

DISCUSSION

HbA1c is not in the target range on metformin alone (as

in this patient), an additional medication would be
beneficial. Many options are available, but the ADA
recommends choosing one of the following agents in
most cases:
Sulfonylurea
Thiazolidinedione
Glucagon-like peptide (GLP)-1 agonist
Dipeptidyl peptidase (DPP)-4 inhibitor
Insulin

DISCUSSION
A number of issues should be considered when choosing
between these medication classes, including:
Patient preference for route of administration and other
factors
Efficacy in reducing HbA1c
Potential to cause hypoglycemia
Potential to induce weight gain
Side effects
Cost

Gliclazide was shown to protect human

pancreatic beta-cells from hyperglycemiainduced apoptosis.

Del Guerra, S; Grupillo, M; Masini, M; Lupi, R; Bugliani,

M; Torri, S; Boggi, U; Del Chiaro, M; et al. (2007).
"Gliclazide protects human islet beta-cells from
apoptosis induced by intermittent high
glucose".Diabetes/Metabolism Research and
Reviews 23 (3): 2348.

It was also shown that GLICLAZIDE have

an antiatherogenic effect (preventing
accumulation of fat in arteries) in type 2
diabetes.

Katakami, N.; Yamasaki, Y.; Hayaishi-Okano, R.; Ohtoshi,

K.; Kaneto, H.; Matsuhisa, M.; Kosugi, K.; Hori, M. (2004).
"Metformin or gliclazide, rather than glibenclamide,
attenuate progression of carotid intima-media thickness in
subjects with type 2 diabetes".Diabetologia 47 (11): 1906
13.

While it was shown to have the same

efficacy as glimepiride, one of the newer
sulfonylureas(GLICLAZIDE), the European
GUIDE study has shown that it has
approximately 50% less hypoglycaemic
confirmed episodes in comparison with
glimepiride
Schernthaner, G.; Grimaldi, A.; Di Mario, U.; Drzewoski, J.;
Kempler, P.; Kvapil, M.; Novials, A.; Rottiers, R.; et al. (2004).
"GUIDE study: Double-blind comparison of once-daily gliclazide
MR and glimepiride in type 2 diabetic patients". European Journal
of Clinical Investigation 34 (8): 53542.

The Power To Control Glycemia

Are Sulfonylureas the same

in treating newly diabetic patients?
Efficacy
Safety
Protection

EFFICACY
means.

Intensive & efficient

efficacy
10.0

Standard glycemic control

Intensive glycemic control (Diamicron MR)

9.5

Mean HbA1c (%)

9.0
8.5

Mean HbA1c
at final visit

P<0.0001

8.0
7.5

7.3%

7.0

6.5%

6.5
6.0
5.5
5.0
0

Follow-up (years)

4/5 < 7%

Adapted glycemic control

Whatever the severity of the disease

Long lasting glycemic control

Satoh Trial

(B-cell Preservation)

Switch from Glibenclamide to Diamicron

MR

Peace of mind
Safe

A glucose-dependent
mode of action
Diamicron MR, unlike glimepiride and
glibenclamide, binds reversibly to the cell receptor.

Diamicron MR

Glimepiride
Glibenclamide

Ashcroft FM, Gribble FM. J Diabetes Complications. 2000;14(4):192-196.

A glucose-dependent
mode of action
Diamicron MR, unlike glimepiride and
glibenclamide, binds reversibly to the cell receptor.
HYPERGLYCEMIA
Diamicron MR

Glimepiride
Glibenclamide

Ashcroft FM, Gribble FM. J Diabetes Complications. 2000;14(4):192-196.

A glucose-dependent
mode of action
Diamicron MR, unlike glimepiride and
glibenclamide, binds reversibly to the cell receptor.
NORMOGLYCEMIA

Ashcroft FM, Gribble FM. J Diabetes Complications. 2000;14(4):192-196.

A glucose-dependent
mode of action
Diamicron MR, unlike glimepiride and
glibenclamide, binds reversibly to the cell receptor.
NORMOGLYCEMIA

Ashcroft FM, Gribble FM. J Diabetes Complications. 2000;14(4):192-196.

Conclusions:
The incidence of Hypoglycaemia was lower with gliclazide relative
to the other sulphonylurea agents and similar to that observed with
sitagliptin.

Strict weight neutrality

Diamicron MR

Strict weight-neutrality over 5 years

1.ADVANCE Group. N Engl J Med 2008; 358:2560-72 /

Protection

Safe glycemic control

Nephro protection

Diamicron MR guarantees

Intensive & efficient glycemic control

Long lasting control

Excellent Practicality (Safe)

Kidney protection

Thank you