A 41-year-old chief executive officer of a corporation has noted increasing thirst over the past 3 months. His fluid consumption has increased, and he is spending more time in rest rooms, which interferes with business meetings. He has not seen a physician for the past 20 years, since discharge from military service. On physical examination his temperature is 37 C, pulse 74/min, respiratory rate 16/min, and blood pressure 140/85 mm Hg. He has decreased sensation to light touch and pinprick in his lower extremities. He has decreased range of movement with crepitus and pain in his knees bilaterally. His BMI is 31.

Laboratory studies show Hgb 13.5 g/dL, Hct 40.7%, MCV 90 fL, platelet count 263,700/microliter, WBC count 8330/microliter, sodium 143 mmol/L, potassium 4.2 mmol/L, chloride 108 mmol/L, CO2 26 mmol/L, glucose 155 mg/dL, creatinine 1.2 mg/dL, total protein 5.8 g/dL, albumin 4 g/dL, and total bilirubin 0.9 mg/dL. A urinalysis shows pH 7, sp gr 1.015, glucose 2+, protein 1+, blood negative, and ketones negative.

Questions:

3.1 What is suggested by these findings?

He has type II diabetes mellitus. He may have osteoarthritis and a peripheral neuropathy. He may have some amount of renal damage from diabetic nephropathy or from atherosclerotic renovascular disease.

3.2 What therapy is indicated?

Start with lifestyle modifications. However, he is resistant to these changes, indicating that he travels and entertains frequently with clients.

Drug therapy may include oral agents:

1. "Oral agents" such as rosiglitazone which are members of the thiazolidinedione class of antidiabetic agents may be used. Thiazolidinediones are agonists for the peroxisome proliferator-activated receptor-gamma (PPAR-gamma), increasing peripheral insulin sensitivity. PPAR receptors are found on adipocytes, myofibers, and hepatocytes. PPAR receptors are found in cell nuclei and upon activation regulate transcription of insulin-responsive genes gluconeogenesis (liver), transport across cell membranes, and utilization within the cell.

2. Sulfonylureas such as glipizide and glyburide increase insulin secretion from beta cells in the islets.

3. Metformin decreases hepatic glucose production and increases peripheral glucose utilization.

4. Alpha-glycosidase inhibitors such as acarbose are complex oligosaccharides that delay digestion of carbohydrates. Of course, eating foods with a low glycemic index can accomplish the same purpose.

5. Insulin is used to treat type 2 diabetes mellitus as a last resort. It is usually given as a combination of short and intermediate acting forms.

Adverse effects of all of the above include hypoglycemia, so patients must watch their diet. The thiazolidinediones also affect fatty acid metabolism and can increase lipids. Metformin use can lead to lactic acidosis.

3.3 How would your assess this patient's compliance or adherence with his diabetes treatment?

Learning to be reinforced: Biological measures of glycemic control (e.g., HbA1C) are inadequate measures of patient behavior. A good assessment will focus on relevant diabetes care behaviors and will not make assumptions about those behaviors based on low or high HbA1C values. Also avoid vague or general questions about what the patient "usually does" to care for his diabetes. One useful approach is to conduct a 24 hr recall of the patient's previous day, starting from the time he got up until the time he went to bed; all relevant diabetes care behaviors are recorded (diet, exercise, medications, glucose testing). It is important to conduct such interviews in a nonjudgmental way. This approach is useful because patient's recall of recent time periods is usually good and it provides very specific information about the patient's diabetes management behavior. This helps the physician target specific behaviors for change.

3.4 You ask the patient to bring in his oral medication and conduct a pill count. He appears to be taking all of his medication as prescribed. You also contact the patient's pharmacy and learn that he has been refilling his prescription on a regular basis. Would you describe this patient as a "compliant" patient?

Key point: This patient appears to be compliant with medication taking. However, "compliance" is not a "trait." Knowing that a patient is compliant with one aspect of a treatment regimen does not permit us to infer that he is or is not compliant with other aspects of the regimen. He may take all his medication but never exercise or blood glucose test. He may eat only one large meal a day or drink lots of cokes. We just don't know unless we assess those aspects of his regimen.

Key point: pill counts have limitations. Patients could "dump" or get rid of their meds before they come to the doctor to "look good." Patients sometimes give their meds to others (e.g., the patients elderly mother has diabetes and cannot afford her medication so he has been giving her his pills which are covered by his insurance policy at work). The fact that all the pills are gone does not tell us anything about the timing of their meds.