Case Study: A 38-year-old Female From Nepal Diagnosed With Type 2 Diabetes

Medical condition of patient

Patient in this case is a 38 years Female form Nepal. She is married and having one child. She was diagnosed with diabetes in 2010. She was diagnosed with myopia at the age of 10. Myopia is condition in which person can see things at less distance but can’t see things at the long distance. Her height is 164 cm and weight is 64 kg. She is living healthy lifestyle with 45 minutes walk on daily basis. She is non-smoker and she doesn’t have habit of alcohol consumption. Both smoking and alcohol consumption can exaggerate the diabetic condition. Her blood glucose level is not stable and it is fluctuating between hypoglycemic and hyperglycemic condition. In this essay case this patient is discussed.

Blood sugar level should be below 7.2 mmol/l in fasting condition and it should be below 10 mmol/l in postprandial condition. However, her fasting and postprandial blood glucose levels are above normal level. HBA1C test is a glycated haemoglobin test. This test indicates average glucose level in the past 2 to 3 months. Normal level of HBA1C should be below 5.6 %. However, her HBAIC level is above 10 %. This HBA1C level indicates her average blood glucose level was approximately 240 mg/dl for 2 – 3 months prior to the tests (Mianowska et al., 2011; Battelino et al., 2011). She was administered with metformin and gliclazide. Two months later initiating this treatment she was prescribed with insulin. In 2014, she migrated from Nepal to Australia. However, she couldn’t avail facility of Government medical insurance because she is on temporary visa. Hence, she opted for the private insurance for her basic cover. Currently, she is consuming medications like Insulin Novo mix 30u mane and 26u nocte, metfromin and acarbose. Her medical tests were performed in January 2017. In these tests it was observed that her condition was improved due to consumption of these medications. Her HBAIC1 levels are below 7 %, random blood glucose in fasting condition is 7 mmol/l, post prandial condition is 12 mmol/l. Her lung function test and renal function test are normal. Normal liver function tests indicate that these administered drugs are not adversely affecting her liver. In few patients, these drugs can induce liver toxicity. Her renal function tests are also normal. It indicates that she doesn’t developed diabetic complication. Renal insufficiency is one of the prominent diabetic complications. Thyroid function test is normal in this case. Thyroid function test should be performed in patients with diabetes because in diabetic patients thyroid dysfunction is very common problem and it can lead to prominent metabolic disturbance. Digital retinal check is with no abnormality detected. Digital retinal test is performed in her because she was diagnosed with myopia at the age of 10 (Hammes et al, 2011).  This essay comprises of diagnostic tests, pathophysiology of diabetes, allied health workers for diabetes, diet and exercise in diabetes.   

Blood glucose level test and HBA1C tests were performed in her for the diagnosis of diabetes. Blood glucose test is generally performed to estimate amount of glucose in the blood. This test is generally used for assessment of both prediabetes and diabetes patient. This test should be performed in fasting condition and postprandial condition. Fasting glucose level should be estimated at around 8 – 14 hours after meals. During fasting, patient should not consume anything other than water. Caffeine can vary results of blood glucose level. Hence, caffeine should not be consumed during fasting. If patient consume food during scheduled fasting period, it may lead to raised blood level. By virtue of this, doctor may make wrong diagnosis of prediabetes or diabetes (ADA, 2016; Kacerovsky et al., 2011).

Diagnostic tests

Blood glucose test can be effectively used in patients with existing diabetes because in diabetes patients frequent estimation of blood glucose is required. Postprandial blood glucose test should be performed after two hours of consumption of food. Blood glucose range between 5.5 to 7 mmol/l in fasting condition indicates likely prediabetes condition. Blood glucose level at 7 mmol/l and above indicate patient at risk of diabetes. In patient mentioned in this case study, fasting blood glucose level is above 14 mmol/l.  Hence, this patient is diabetic. Blood glucose level less than 8 mmol/l after 90 minutes of food is considered as normal. However, postprandial blood glucose level of patient mentioned in the study is 28 mmol/l. Hence, this patient has diabetes. Random glucose level test should be performed irrespective of the time of eating. Random glucose level test is generally performed to evaluate variation in the glucose level in a day. In normal patient, blood glucose level generally remains same throughout the day. In diabetes patients blood glucose level would vary considerably. Patient mentioned in the case study exhibited substantial variation in the blood glucose level. Blood glucose level is generally estimated by using glucose meters. Glucose meters comprise of glucose strips which give concentration of glucose level. Glucose can also be estimated using glucose oxidase method. HBA1C test is generally used for estimating average glucose level in the patient. This test gives estimate of glucose level in the last 2 – 3 months. It specifically estimates accumulation of blood glucose in the red blood cells. This test is also useful for monitoring therapeutic effect of medicine (Selph et al., 2015). HBAIC can be estimated by using commercial ELISA kits available in the market. HBAIC levels between 4 to 5.6 % indicate normal level. HbA1C level between 5.7 to 6.4 indicate prediabetes condition of the person. HbA1C level above 6.5 % indicate diabetes in the person. Mentioned HBAIC level is above 10 % in this patient. Hence, HbA1C estimation indicates diabetes condition of the patient (Pagana and Pagana, 2014).

Patient in the case study has type 1 diabetes. Type 1 and type 2 diabetes can be diffentiated based on the insulin resistance. In type 2 diabetes patients there is occurrence of insulin resistance. Hence, insulin can be useful as a treatment option in very few diabetes patients. Clinical symptoms or blood glucose diagnostic tests can’t distinguish between type 1 and type 2 diabetes. Patient in the case study is responding effectively to insulin as compared to other glucose lowering agents. Hence, this patient has type 1 diabetes (Holt et al., 2016).      

In type 1 diabetes immune system act on the insulin producing beta cell and destroys these cells. Deficiency of beta cells leads to deficiency of insulin because these beta cells perform function of insulin secretion. Type 1 diabetes develops after the destruction of approximately 80-90 % beta cells. Type 1 diabetes is called as autoimmune disease because there is presence of anti insulin or anti islet cell antibodies. Islet cell antibodies are generally directed against pancreatic beta cell enzyme like glutamic acid decarboxylase (GAD). Viral infection triggers autoimmune response in type 1 diabetes patient. Viral infection produces antibodies against viral protein and this immune response is similar to the immune response against antigenically similar beta cells (Vehik et al., 2011; Yeung et a., 2011). This leads to the infiltration of the lymphocytes and consequently pancreas islets get destructed. Irrespective of the destruction of the pancreas, disease occurs in few days or weeks. Due to deficiency of insulin, hyperglycemia develops in the patients with type 1 diabetes. It is evident that patient in the case study also has high level of blood glucose (Simpson et al., 2011).

Pathophysiology of diabetes

Type 1 diabetes patients require insulin for its treatment and these patients would not exhibit improvement with insulin sensitizing oral medications. Metformin is administered in this patient to control glucose level. This drug acts by inhibiting hepatic gluconeogenesis. Due to inhibition of hepatic gluconeogenesis, there is suppression of hepatic glucose production. Generally, metformin is not useful in type 1 diabetes patients, however in few patients there is possibility of insulin resistance. In such patients metformin would be useful as it reduces insulin requirement (Hu et al., 2016). In this patient, Gliclazide is also administered. Gliclazide acts by inhibiting sulfonylurea receptors (SUR-1) on the pancreatic beta-cells. As this medication is not useful in type 1 diabetes patients, it was discontinued. Acarbose is also administered to patient in the case study. Acarbose acts by inhibiting enzymes like alpha-glucosidase in small intestine and alpha amylase in the pancreas (Singla et al., 2016). By virtue of this digestion of carbohydrate occurs. In long term acarbose is useful in reducing HbA1C level. Hence, this drug is administered in this patient. Insulin (Novo mix 30/70) is administered subcutaneously to this patient to reduce glucose level. Insulin binds to the receptors of fat and muscle cells and facilitate glucose uptake. Insulin also inhibits glucose release form the liver. This is a mixture of rapid-acting and intermediate-acting insulin in the ratio of 30/70 (Aathira and Jain, 2014; Garg et al.,2011; Birkeland et al., 2011).      

Patient in the case cannot offer to have other allied workers. Hence, she may be in need of counseling for diet, exercise and psychological problems. Nurse should advise her about food. Nurse should teach her carbohydrate counting, ask her to take balanced food, request her to coordinate meal and medication and to avoid sweetened beverages. Nurse should ask her to make exercise schedule, stay hydrated during exercise and change medication usage based on the exercise. Nurse should tell her that she should not take stress of illness because it can exaggerate her condition. Due to stress different hormones released in the blood and it detoriate overall health (Holt et al., 2016).    

Gluten containing cereals increase risk of islet cell antibodies formation. Hence, increase risk of type 1 diabetes. In the studies, it has been found that gluten free diet is helpful in improving diabetes condition. Food containing niacinamide (vitamin B3) is useful in the prevention of diabetes. Patient should maintain meal timing consistently every day. Patient should take small quantity of meals with frequent intervals. Meal containing high fat should be taken occasionally and blood glucose should be monitored closely during this time. Patient should take food containing fruits, vegetable, whole grains, legumes and low fat milk. Patient should plan exercise and physical activity based on the diet and doses of insulin. Patient should monitor blood glucose level before and after exercise (Bricklin, 2013). If exercise is lowering blood glucose level, patient should lower dose of insulin and consume optimum amount of carbohydrate. Patient should fix the duration of exercise based on trial and error basis.

Allied health workers for diabetes

In case of improper management of type 1 diabetes, many complications can occur. Prominent type 1 diabetic complications include heart disease, stroke, kidney failure, foot ulcers and retinopathy. In case of excessive insulin treatment, there is possibility of occurrence of hypoglycemia. Type 1 diabetes also increases chances of urinary tract infection, sexual dysfunction and polycystic ovarian syndrome (PCOS) in famales (Gregg et al., 2016; Lagani et al., 2013). From the literature it is evident that approximately 12 % of the type 1 diabetic patients develop clinical depression. Elevated levels of glucose for the long duration also affects nervous system and lead to peripheral neuropathy which results in the pain and loss of feeling in the extremities (Handelsman et al., 2011).  

Incorporation of professionals from different disciplines is important in the management of diabetic patient because diabetes is a multifactorial disease. Other than medical treatment, intervention should be provided for regular exercise, proper diet, clinical diagnosis, cardiovascular complications and psychological stress due to diabetic condition.  Hence, along with doctors, nurses and pharmacist there should be incorporation of other allied health professionals like clinical laboratory scientist, optometrist, clinical psychologist, dietitian, cardiovascular technologist, electrocardiogram technician and exercise physiologist. However, this patient cannot offer other allied health care professionals only clinical laboratory scientist and optometrist should be incorporated in her care and diabetes management (Holt et al., 2016).

Resource available for diabetes education in Australia are Australian Diabetes Educators Association (ADEA), Diabetes Australia, Nutrition Australia, Baker Institute, National Diabetes Services Scheme, Endocrine Society of Australia, Government of health, Australia, Diabetes SA and Australian Institute of Health and Welfare.  

Patient mentioned in this case study is suffering through type 1 diabetes. Patient has very high glucose and HBAIC level. Glucose and HBAIC level were estimated using glucometre and HBAIC kit respectively. Initially patient was administered with metformin and gliclazide. However, there was no improvement in the patient. Hence, administration of gliclazide was suspended and insulin treatment was initiated. Metformin, acarbose and insulin produced beneficial effects in the patient. Along with medication management, type 1 diabetes patient should also be monitored for food intake and exercise. In summary, type 1 diabetes patients can be effectively treated with insulin administration.

References:

American Diabetes Association (ADA). (2016). Standards of medical care in diabetes-2016: summary of revisions. Diabetes Care, 39(0), pp. S4-S5.

Aathira, R., and Jain, V. (2014). Advances in management of type 1 diabetes mellitus. World Journal of Diabetes, 5(5),  pp. 689-96.

Battelino, T., Phillip, M., Bratina, N., Nimri, R., Oskarsson, P., and Bolinder, J. (2011). Effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes. Diabetes Care, 34(4), pp. 795-800.

Birkeland, K.I., Home, P.D., Wendisch, U., Ratner, R.E., Johansen, T., Endahl, L.A., et al. (2011). Insulin Degludec in Type 1 Diabetes: A randomized controlled trial of a new-generation ultra-long-acting insulin compared with insulin glargine. Diabetes Care, 34(3), pp. 661-5.

Bricklin, M. (2013). The Diabetes Rescue Diet. Rodale.

Garg, S.K., Voelmle, M.K., Beatson, C.R., Miller, H.A., Crew, L.B., Freson, B.J., et al. (2011). Use of Continuous Glucose Monitoring in Subjects With Type 1 Diabetes on Multiple Daily Injections Versus Continuous Subcutaneous Insulin Infusion Therapy: A prospective 6-month study. Diabetes Care, 34(3), pp. 574-9.

Gregg, E.W., Sattar, N., and Ali, M.K. (2016). The changing face of diabetes complications.

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Hammes, H.P., Kerner, W., Hofer, S., et al. (2011).  Diabetic retinopathy in type 1 diabetes-a contemporary analysis of 8,784 patients. Diabetologia, 54(8), pp. 1977-1984.

Handelsman, Y., Mechanick, J.I., Blonde, L., Grunberger, G., Bloomgarden, Z.T., Bray, G.A., et al. (2011). American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Endocrine Practice, 17 (2), pp. 1-53.

Holt, R.I.G., Cockram, C., Flyvbjerg, A., and Goldstein, B.J. (2016). Textbook of Diabetes. John Wiley & Sons.

Hu, J., Zou, P., Zhang, S., Zhou, M., and Tan, X. (2016). Empagliflozin/metformin fixed-dose combination: a review in patients with type 2 diabetes. Expert Opinion on Pharmacotherapy, 17(18), pp. 2471-2477.

Kacerovsky, M., Jones, J., Schmid, A.I., et al. (2011). Postprandial and fasting hepatic glucose fluxes in long-standing type 1 diabetes. Diabetes,  60(6), pp. 1752-8.

Lagani, V., Koumakis, L., Chiarugi, F., Lakasing, E., and Tsamardinos, I. (2013). A systematic review of predictive risk models for diabetes complications based on large scale clinical studies.

Journal of Diabetes and its Complications, 27(4), pp. 407-13.

Mianowska, B., Fendler, W., Szadkowska, A., Baranowska, A., Grzelak-Agaciak, E., Sadon, J., et al. (2011). HbA(1c) levels in schoolchildren with type 1 diabetes are seasonally variable and dependent on weather conditions. Diabetologia, 54(4), pp. 749-56.

Pagana, K.D., and Paganam T.J.  (2014). Blood studies. In: Pagana KD, Pagana TJ, eds. Mosby’s Manual of Diagnostic and Laboratory Tests. 5th ed. St Louis, MO: Elsevier Mosby; 2014:chap 2.

Selph, S., Dana, T., Blazina, I., Bougatsos, C., Patel, H., Chou, R. (2015). Screening for type 2 diabetes mellitus: a systematic review for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 162(11), pp. 765-776.

Simpson, M., Brady, H., Yin, X., et al.(2011).  No association of vitamin D intake or 25-hydroxyvitamin D levels in childhood with risk of islet autoimmunity and type 1 diabetes: the Diabetes Autoimmunity Study in the Young (DAISY). Diabetologia, 54(11), pp. 2779-88.

Singla, R.K., Singh, R., and Dubey, A.K. (2016). Important Aspects of Post-Prandial Antidiabetic Drug, Acarbose. Current Topics in Medicinal Chemistry, 16(23), pp. 2625-33.

Singh, A.K., and Singh, R. (2016). Is gliclazide a sulfonylurea with difference? A review in 2016. Expert Review of Clinical Pharmacology, 9(6), pp. 839-51.

Vehik, K., Beam, C.A, Mahon, J.L., et al. (2011). Development of Autoantibodies in the TrialNet Natural History Study. Diabetes Care, 34(9), pp. 1897-1901.

Yeung, W.C., Rawlinson, W.D., and Craig, M.E. (2011).  Enterovirus infection and type 1 diabetes mellitus: systematic review and meta-analysis of observational molecular studies. British Medical Journal, 342, p. d35.