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Would YOU Have Done It?

Posted Nov 01 2010 2:24pm
You were disappointed.

Your patient, showing a hemoglobin_A1c of 6.8% in April (2010), now shows an A1c of 7.6% (goal = 7.0% or under) at a visit in July 2010. She's also gained 5 pounds.

You review the patient’s history. She’s 64 years old and you’ve followed her for 6 years. Her Type 2 diabetes was initially diagnosed 10 years ago. Since that first visit 6 years ago, you had managed to lower her A1c from 9.9% to 6.8% by April 2010 .... and she hasn't helped very much. Along the way, you’ve confirmed she’s not compliant with the diabetic diet and pretty much refuses to exercise.

Your level of concern rises now that the A1c has risen out of the goal range. You confirm there is no other clear explanation for the rise (concomitant illness, change in medications, etc.). You note her total weight gain, since the initial visit 6 years ago, is now at 26 pounds. She’s 219 pounds at a height of 5’3”. Therefore, she's about 85 pounds above ideal body weight. You realize the improvement in blood sugar control has contributed to the weight gain through the years, especially against the background of little compliance with diet and exercise. Weight gain is often seen with improving blood sugar control as the patient no longer has the “calorie leak” of spilling hundreds of calories each day (in the form of sugar) in the urine when blood sugars are uncontrolled.

You’ve achieved the improvement in this patient’s blood sugars with sequential adjustments to maximum doses of METFORMIN, GLIPIZIDE-ER and JANUVIA. The JANUVIA was started when she refused to consider BYETTA a few years ago. You confirm she’s seen some blood sugars > 200 mg/dl recently when she self-tests an occasional blood sugar.

You realize, based on her history, that she’s likely going to continue “out-eating” anything else you add to her medication regimen. You wonder why you've explained the benefits of exercise for the 8th or 9th time. You've listened each time as she laughingly claims she has a treadmill, and other exercise equipment, but they serve only as a place to hang clothes.

You realize you have to do something ... and she's not going to help. Therefore, you take a chance, again, with an injectable incretin mimetic . This time, you suggest VICTOZA, hoping she’ll be willing to inject once daily instead of the twice daily needed with the BYETTA she previously refused. However, you have a bit more “ammunition” at this time. You can tell her that she'll be injecting "something else" if she refuses VICTOZA -- that "something else" is insulin.

She agrees to VICTOZA therapy and sequentially moves to the 1.2 mg daily dose. No other changes are made in her therapy at the time.

You see her back about 7 weeks later. She has lost 2 pounds, but the A1c has risen to 8.0%. The fasting blood sugar is OK at 123 mg/dl.

Based on what you’ve seen in most patients starting VICTOZA, you are disappointed with these initial results. You begin more specific questioning in an attempt to understand what has happened. She simply laughs when you ask about exercise, but you get your answer when you ask about the diet
“Oh, that. My blood sugars looked so much better after I started the VICTOZA that I have been eating a lot more carbohydrates ... you know, like potatoes and bread.”

Would you have started banging your head on the wall in absolute frustration?

I thought about it ..... but didn't.

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