*** CASE STUDY 10 Elderly Poorly Controlled Diabetes on Insulin

Dated: 18 September 2007 (Final edition 21 January 2008)

Patient’s Name: Kwok C.L. NIRC: S05*****F

*** Submitted to SNB for APN Certification

TABLE OF CONTENTS
Page
1. Patient Profile 2
2. Health Assessment 2
3. Physical Examination 3
4. Diagnosis 4
5. Management 5
6. Evaluation 9
7 APN Reflection and Learning Points 9

Mr Kenneth Kwok, a 68-year old gentleman, has diabetes and hyperlipidemia for 7 years.
Recently in November 2006, he was diagnosed with early diabetic nephropathy and
hypertension. He started on insulin therapy in addition to his oral antihyperglycemic agents on
12 August 2006. This case study will be based on the visit 07 April 2007 focusing on the
management of diabetes mellitus in an elderly patient on insulin injections.

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PATIENT PROFILE
Mr Kenneth Kwok (S05*****F) is a 68-year old gentleman who has diabetes and
hyperlipidemia for 7 years. He started on insulin therapy in addition to his oral hypoglycemic
agents on 12 August 2006. In November 2006, he was diagnosed with early diabetic nephropathy
after 2 episodes of increased albumin : creatinine ratios of 30 to 300mg/g. There are no other
diabetic microvascular and macrovascular complications. During his last visit to the polyclinic
on 14 November 2006, he was noted to have elevated blood pressure reading of 142/ 90mmHg
for the second episode. This case study will focus on the management of diabetes mellitus in an
elderly patient on insulin injections.

HEALTH HISTORY
Chief Complaint: I saw Mr Kwok and his wife on 07 April 2007 for his usual medical review.
Mr Kwok felt well and had no complaints. Mr Kwok’s injections were given by Mrs Kwok and
his wife cited the night insulin dosage correctly. In particular, there were no hypoglycemic
episodes. His fasting home glucose monitoring ranged from 5.5 to 5.7mmol/L. His HbA1C%
was 7.9% with a fasting blood glucose of 7.5mmol/L. His Lovastatin dose of 20mg at night had
been changed to Simvastatin 15mg the previous visit due to the sub-optimal control of low-
density lipoprotein at the level of 3.00mmol/L. He claimed to be compliant and tolerant to the
change of statins from Lovastain 20mg to Simvastatin 15mg every night. He experienced no
muscle pain, tenderness or weakness from the medication.

SOCIAL HISTORY
Mr Kwok is a retiree currently living with his wife. His children are married and staying with
their own family units. This elderly couple has to cope with managing their chronic diseases.
Mrs Kwok also has diabetes mellitus but she is only on oral hyperglycemic agents. Her glycemic
control is better than Mr Kwok. Mrs Kwok draws the insulin dosage and administers the insulin
injection every night for Mr Kwok at 10pm. Both of them usually eat at home where the food is
prepared by Mrs Kwok. Recently, Mr Kwok had been drinking Pokka green tea, 100 Plus and
Yakult about 3 times a week due to the hot weather and constipation. Mr and Mrs Kwok walk
around the block after dinner time about 3 times a week, 20 minutes each time. However, they
cannot walk further due to the pain in Mr Kwok’s osteoarthritic knees.

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DRUG ALLERGY: None known.

CURRENT MEDICATIONS:
· Glipizide 15mg twice a day.
· Metformin 850mg three times a day.
· Subcutaneous Humulin N 10 units every night.
· Enalapril 5mg every morning
· Simvastatin 15mg every night.

PHYSICAL EXAMINATION
General appearance – Looks comfortable.
BMI – 33.8 (Height 1.72m and weight 100kg)
Nails – No pallor and clubbing seen.
Tongue – Moist and pink.
a) CVS examination
Pulse – 72 beats per minute. Regular in rhythm.
Blood Pressure – 136/90mmHg. Home BP is also around 140/90mmHg
Heart – Apex beat was palpable at the 5th intercostal space on the left mid clavicular line. There
were no thrills or parasternal heave felt. S1 and S2 heart sounds were heard. No murmurs were
detected. Jugular venous pressure was not raised. There was no pedal oedema.
b) Lungs examination
Lungs – Chest expansion was equal bilaterally. Bilateral vesicular breath sounds were heard
symmetrically. No crepitations or wheezes were heard.
c) Abdomen examination
Abdomen – Abdomen soft and non-tender. No lipohypertrophy seen. There is no organomegaly.
Kidneys are non-ballotable. There are no renal bruits.

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Laboratory Tests

Aug 06 Sep 06 Nov 06

HbA1C% 8.8% -- 7.4%
FBS (mmol/L) -- 6.2 --
HBGM (mmol/L) -- 4.7 to 5.6 --
BP 130/80mmHg 146/90mmHg 142/90mmHg
LDL -- -- --
Glipizide 15mg BD Same Meds Increase Metformin 850mg TDS
Metformin 850mg BD TCU 8 weeks Add Enalapril 5mg OM
Lovastatin 20mg ON Others remain same
Medications Add Humulin N 10 units TCU 8 weeks with K+, Na+ and
ON Creatinine
TCU 4 weeks

Jan 07 Apr 07
HbA1C% 7.6% 7.9%
FBS (mmol/L) -- 7.5
HBGM (mmol/L) 5.6 to 7.6 5.5 to 5.7
BP 136/ 94mmHg 140/ 90mmHg
LDL 3.00mmol/L 2.80mmol/L

Wants to try diet modification instead of increasing Today consult.

insulin.
Medications Change Lovastatin to Simvastatin 15mg ON.
Others remain same.
TCU 12 weeks with HbA1C%, FBS, Lipids, ALT, AST.

DIAGNOSES
· Diabetes mellitus on insulin therapy
· Diabetic nephropathy
· Hyperlipidemia
· Hypertension
· Osteoarthritis knee

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MANAGEMENT
In general, diabetes management of Mr Kwok should be focused on 3 main areas, glycemic
control, blood pressure regulation and cholesterol management.

Mr Kwok’s Glycemic Profile. Mr Kwok’s glycosylated haemoglobin (HbA1C%) deteriorated

from a 7.6% to a 7.9%. HbA1C% is a 3-monthly indicator of the glycemic control. An
acceptable HbA1C% of 7% might indicate a consistent level of blood glucose around 8.4mmol/L
, or may depict a range of too “high” and too “low” fasting blood glucose averaging to 7%. An
HbA1C% of 7.9% actually indicates an average blood glucose level of about 10mmol/L (Nathan,
Turgeon and Regan, 2007). However, in Mr Kwok’s case, his fasting home blood glucose is
5.5mmol/L to 5.7mmol/L. The pattern of a high HbA1C% in contrast to optimal home fasting
blood glucose readings indicates that Mr Kwok has many episodes of hyperglycemia in the midst
of his good fasting glucose readings. This led me to probe Mr Kwok on the change in his dietary
and exercise habits. He admitted to drinking Pokka Tea, Yakult and 100 Plus soft drinks about 3
times a week which are sugary drinks. These contributed to the increased HbA1C% from 7.6%
to 7.9%. His weight has also increased from 97kg to 100kg in a 3-month period. According to
Hirsch et al, (2005), the relative contribution of fasting glucose to overall glycemic control is
70% in patients with a HbA1C% more than 10.2%; this contribution of fasting glucose decreases
as HbA1C% decreases. Thus in Mr Kwok’s case, the focus will be on postprandial glucose
spikes.

I advised Mr Kwok to stop all his sugary drinks. Coke Light and Pepsi Light (soft drinks with
aspartame) are suggested to substitute his 100 Plus and Pokka Tea during hot weather. In
addition, asking him to add more fiber to his daily meals and drink more water to relieve his
constipation, in the hope that he can stop his reliance on Yakult. My intention is to lower Mr
Kwok’s postprandial spikes through diet control.

Insulin Management for Mr Kwok. Theoretically, the ideal insulin therapy regimen should
mimic normal physiologic insulin release. The risks of insulin therapy include weight gain,
hypoglycemia and, in very rare cases, allergic and cutaneous reactions (DeWitt and Hirsch,
2003). According to Mayfield and White (2004), the starting insulin dose for insulin therapy is
calculated as 0.2 units per kg per day. Another safe calculation is units of insulin per day equals

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fasting plasma glucose level in mmol per L. Supplemental (or correctional) insulin is added or
subtracted to bring the pre-meal or bedtime glucose levels into the desired range. Insulin
sensitive patients require 1 unit of insulin to change the blood glucose level by 2.8mmol/L;
insulin-resistant patients experience a smaller change (Mayfield and White, 2004). Another
recommendation for dose titration in once-daily or twice daily insulin regimen is shown in Table
1 (Hirsch et al, 2005).
FBS Most Values Dosage Change
(during last 3 to 7 days)
< 4.4mmol/L -2 units
4.4 to 6.0mmol/L No Change
6.1 to 7.7mmol/L +2 units
7.8 to 9.9mmol/L +4 units
More than or equal to 10mmol/L +6 units
Table 1: Dosage Titration for Once-Daily or Twice-Daily Insulin Regimens

In Mr Kwok’s case, if we want to correct his night insulin regimen, his fasting blood glucose
during the consult of 7.5mmol/L has a difference of 2.5mmol/L when corrected to 5.0mmol/L. In
this scenario, an increase of 1 to 2 units of insulin to the night regimen might be appropriate. The
decision to increase night basal insulin should be carefully balanced between reaching the
optimal target, risks of hypoglycemic episodes and patient’s acceptance. For Mr Kwok, a small
incremental dose of basal insulin will not directly address the postprandial hyperglycemia,
although it might have a slight improvement in the overall HbA1C%.

I also advised Mr Kwok to provide a home blood glucose profile in the next visit for refining
insulin therapy. Prior to night insulin, glucose readings at about 10pm and 2 hours post lunch
readings will be useful in deciding the need to add morning insulin as the next step in
management. Thus during this consult visit, it had been emphasized to Mr Kwok that he had to
watch his diet, stop all his sugary drinks and perform 2 hours post lunch and pre-night time
injection glucose readings.

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Should we maintain the combination of OHGA with insulin or slowly reduce OHGA to keep Mr
Kwok’s on insulin alone? There had been studies that Metformin with insulin causes less weight
gain, lower insulin requirement and fewer hypoglycemic episodes than insulin alone or insulin
with Sulfonylureas (DeWitt and Hirsch, 2003). Metformin and insulin seem to be the best
combination for majority of Type 2 diabetes patients unless contraindicated. Combining
Sulfonylureas with insulin has also shown to reduce insulin doses by 25% to 50% with less
weight gain. However, as insulin production declines and HbA1C levels approach 10%, the
combination of insulin and Sulfonylureas eventually becomes ineffective. Since Mr Kwok’s
HbA1C% is below 8% for the time being, it is appropriate to continue using Sulfonylurea in the
management. However, I will monitor Mr Kwok’s renal function closely and start to decrease the
dosage of Metformin and increasing insulin dosage in the next few visits if indicated.

Cholesterol Management. Mr Kwok’s low-density lipoprotein level (LDL) has dropped from
3.0mmol/L to 2.80mmol/L with a change of Lovastatin 20mg to Simvastatin 15mg in the last
visit. He is tolerant to the statins as Mr Kwok did not experience any side effects like muscle
pain, tenderness or weakness and his liver enzymes remain in the normal range (ALT: 18U/L,
AST: 17UL). However, the LDL reading has not reached the intended target of less than
2.60mmol/L for diabetic patients. Mr Kwok’s initial LDL is unknown to the polyclinic as he was
already started on Lovastatin 10mg prior to joining Hougang polyclinic. The initial LDL level
prior to treatment will be a good guide for the estimation of statins dosage. In this case, a step-
wise increase of Simvastatin 15mg to 20mg with reinforcement in diet control and exercise will
be appropriate. The expected reduction of LDL on Simvastatin 20mg versus Lovastatin 20mg is
about 32% to 29% (Law, Wald and Rudnicka, 2003). Liver enzymes have to be rechecked in 2
months especially in elderly and those with impaired renal function when dosages increase.
Fasting lipids can also be monitored about 3 months apart to evaluate the effectiveness of
increased statins dosage.

Blood pressure management. Blood pressure control for all diabetes should be less than
130/80mmHg. For a diabetes patient with overt nephropathy, the blood pressure target is
120/75mmHg according to Ministry of Health, Diabetes Mellitus Clinical Practice Guidelines
(2006). Mr Kwok was newly diagnosed to have hypertension with 3 episodes of elevated blood
pressure readings at the last visit. Based on today’s consult blood pressure of 140/90mmHg, his

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blood pressure control is considered sub-optimal. Mr Kwok has early diabetic nephropathy with
albumin : creatinine ratio (ACR) of 30 to 300mg/g. Mr Kwok was already on Enalapril 5mg
every morning which is appropriate, as recommended by the guidelines that ACE inhibitors
introduction can retard progression of renal disease. In retrospective, as Mr Kwok is only on
Enalapril 5mg every morning, it will be appropriate to optimize his management by increasing
the Enalapril 5mg to twice a day for better blood pressure control.

Early diabetic nephropathy management. In Mr Kwok’s case, good glycemic control is important
as it can delay renal disease progression. Yearly, monitoring of ACR is essential. If the ACR
goes beyond 300mg/g, 24hours urine total protein (UTP) and creatinine clearance test (CCT)
ought to be done and monitored 6-monthly to yearly depending on the severity. However, there
are also limitations in obtaining a representative urine collection for 24hours protein and
creatinine evaluation in the polyclinic setting. Thus, serum creatinine levels can be used to
calculate the glomerular filtration rate (GFR) using Cockcroft-Gault equation or MDRD formula.
In NHG Polyclinics, the Chronic Disease Management Registry is an electronic database that
captured all the chronic patients’ clinical indicators and it is able to generate the estimated GFR
(eGFR). Mr Kwok’s eGFR for January 2007 with a creatinine level of 103mmol/L was
66ml/min/1.73m2 . The GFR calculated from serum creatinine level however needs to be used
with caution as there are certain factors that rise creatinine levels e.g. fever, exercise, increasing
age, muscle mass loss etc. Limitations aside, GFR is a good estimate of renal function in the
management of a diabetes patient with microalbuminuria. Besides, staging the progression of the
chronic kidney disease, the GFR also serves as a guide to diabetes management e.g. needing to
stop long-acting sulphonylureas and metformin when it reaches Stage 3 <60ml/min/1.73 m2 .
Referral to the renal specialist is warranted if Mr Kwok has any of the following: a) creatinine
goes above 200umol/L, b) 24hrs UTP >1g/day, c) CCT <30ml/min, d) proteinuria associated
with haematuria, e) poorly controlled blood pressure, f) presence of a renal bruit, g) unexpected
or rapid decline in renal function e.g. acute on chronic renal failure secondary to conditions
leading to hypovolaemic status like GE and h) difficulties in hyperkalaemia. Management of
early diabetic nephropathy includes minimizing further damage to kidneys e.g. treat urinary
infection and avoid use of non-steroidal anti-inflammatory drugs (NSAIDs).

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Mr Kwok was discharged from the consult with the following medications:
1) Glipizide 15mg twice a day.
2) Metformin 850mg three times a day.
3) Subcutaneous Humulin N 10 units every night.
4) Enalapril 5mg every morning
5) Simvastatin 20mg every night. (Increased0

Mr Kwok was given 8 weeks follow-up appointment. During the next follow up, the following
tests will be done 2-hour post-prandial glucose and liver enzymes (ALT and AST).

EVALUATION
During the next follow up appointment, evaluating the following as part of the management is
appropriate: (a) liver enzymes in relation to increased statins (b) health behavior change in
substituting or stopping all sugary dinks and (c) home blood glucose monitoring profile of 2-hour
post lunch and pre-night injection readings. Evaluating the clinical blood pressure and home
blood pressure readings which had not been emphasized during the last consult should be
considered seriously in the next consult. The 2-hour post prandial glucose and home blood
glucose profile will give a guide to the need for converting once-daily insulin injection to twice-
daily regimen. The decision to change the insulin regimen to twice daily will require the
practitioner to assess the timing of the meals and ensure strict consistency of the timing of
injections with meals.

APN RFLECTION AND LEARNING POINTS

This is one of the typical Diabetes Mellitus patients an APN will manage in the polyclinic
setting. From this case study, I have learnt insulin management in elderly and the clinical
decisions required according to the change in glycemic indicators and overall physiological
changes (e.g. renal function, hepatic function, etc.). I have also learnt the management of
Diabetes Mellitus which encompasses managing hypertension, hyperlipidemia and screening of
diabetes complications.

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REFERENCES
DeWitt, D.E. and Dugdale, D.C. (2003). Using new insulin strategies in the outpatient treatment
of diabetes – clinical applications. Journal of American Medical Association, 289(17), p. 2265-
2269.

Hirsch, I.B. et al (2005). A real-world approach to insulin therapy in primary care practice.
Clinical Diabetes, 23(2), p.78-86.

Law, M.R., Walk, N.J. and Rudnicka, A.R. (2003). Quantifying effect of statins on low density
lipoprotein cholesterol, ischaemic heart disease and stroke: systematic review and meta-analysis.
British Medical Journal, 326, p 1423-1430.

Mayfield, J.A. and White, R.D. (2004). Insulin therapy for type 2 diabetes: resuce, augmentation,
and replacement of beta-cell function. American Academy of Family Physician, 70(3), p.489-
500

Ministry of Health (2006). Diabetes Mellitus Clinical Practice Guidelines.

Nathan, D.M., Turgeon, H. and Regan, S. (2007). Relationship between glycated haemoglobin
levels and mean glucose levels over time. Diabetologia, September (13), retrieved from
http://www.springerlink.com/content/33x337022x781218/fulltext.pdf on 13 September 2007.

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