Author: Dr. Lubna Mirza abd Dr. Niharika Pant

Diabetes is a chronic disease with multiple complications. We present a case of a woman with diabetes who presented to our clinic with uncontrolled blood sugar levels and related complications. This case has several learning points that can help other people with diabetes take better control of their disease.

A 65-year-old woman with type 2 diabetes mellitus for the last 15 years presented to the clinic with a burning sensation and itching in both legs. She had a urinary tract infection 2-3 times in the last year. She also experienced frequent abdominal discomfort and loose stools. Her recent lab reports revealed fasting blood glucose of 202mg/dl and HbA1c (hemoglobin A1c which represents the average of blood sugars over the last three months) of 8.3%. Her urine microalbumin (proteins in urine which is one of the complications of diabetes) was 674.1 and her microalbumin/creatinine ratio was 177.3. LDL Cholesterol was 131 mg/dl. One month ago, she had one episode of hypoglycemia (low blood sugar) where her sugar dropped to around 60-70mg/dl. Her maximum fingerpick blood sugar levels reach up to 270-275mg/dl. She is currently on Vildomet (50mg+1000mg). She has never taken insulin. She takes losartan infrequently for high BP readings. Blood pressure medication should be taken regularly every day. In light of the above, we concluded, that she has uncontrolled diabetes mellitus, which requires in-depth evaluation and a change in the treatment plan to prevent life-threatening complications.

We identified the following problems in this case that needed to be addressed.

1) HIGH BLOOD SUGAR LEVELS

The American Diabetes Association treatment goals.

  • HBA1c 7% for most type 2 diabetic adults.
  • Fasting blood sugar of 90-130mg/dl.
  • Blood sugars after 2-hour post-meal are less than 180mg/dl

Any value higher than the above-mentioned value suggests uncontrolled diabetes and requires a change in the treatment plan.

2) RECURRENT INFECTIONS

Uncontrolled blood glucose levels decrease an individual’s immune response and increase the susceptibility to infections like

  • Gastrointestinal infections
  • Urinary tract infections
  • Respiratory tract infections
  • Skin infections and soft tissue infections especially diabetic foot ulcers
  • Yeast infection
  • Head and neck infections

These infections could lead to life-threatening sepsis if not treated on time. One-time Pneumococcal vaccine and yearly Influenza vaccine are a must. Patients should also keep up with the COVID vaccines during the current pandemic.

3) POLYURIA, POLYDIPSIA, POLYPHAGIA (urinating excessively, drinking a lot of water, and eating a lot. These are classic symptoms of poorly controlled diabetes)

Polyuria is defined as excess urine output of more than 3 liters/day. Excess glucose in the blood is excreted in the urine. Excess glucose in urine results in excess loss of water from the body. This in turn causes dehydration which results in constant dry mouth and thirst. The excess glucose in the blood cannot be utilized due to a lack of insulin or insulin resistance. This constant lack of energy leads to polyphagia. There is a lot of sugar circulating in the body but it’s not getting inside the cells where it can be used for energy due to problems with the insulin system.

4) Risk for HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS) or DIABETES KETOACIDOSIS (DKA)  

It is an emergency condition when blood glucose levels above 600mg/dl for a prolonged period lead to polyuria, extreme thirst, vision disturbances, and confusion. If left untreated it can lead to swelling of the brain, seizures, coma, organ failure, and death. DKA occurs mostly in type 1 diabetic patients but it can also happen in type 2 diabetes. It’s an emergency that requires prompt care.

5) KIDNEY DISEASE

Diabetes remains the leading cause of kidney failure with the need for hemodialysis in diabetic patients. Over time, high blood sugars affect the kidney’s filtering system. The signs of kidney compromise are

  • Sudden worsening of blood pressure
  • Proteinuria
  • Swelling of the body starting with periorbital edema
  • Declining urine production
  • Confusion, nausea, vomiting, fatigue

The earliest sign of diabetic nephropathy is the presence of albumin in the urine. Along with maintaining blood sugars, it is vital to keep blood pressure under control.

6) CARDIOVASCULAR DISEASE (CVD)

Cardiovascular disease is the leading cause of death in diabetic people. We recommend screening for high-risk patients since heart disease can be silent in older diabetic individuals, especially women. High blood pressure, high cholesterol levels, and obesity increase the risk of mortality. CVD can precipitate in the form of atherosclerosis, heart failure, or arrhythmias. The symptoms are

  • Chest pain
  • Shortness of breath
  • Fatigue
  • Weakness or numbness in hands and feet

7) PERIPHERAL NEUROPATHY

Diabetes remains the leading cause of foot amputations due to nerve damage in feet. High blood sugars for prolonged periods lead to peripheral neuropathy presenting as a burning and tingling sensation in both upper and lower extremities. Loss of sensation is usually in glove and stocking patterns. However, mononeuropathy (involvement of a single nerve, for example, median, ulnar, radial nerve) is also common. Due to the inability to sense hot, cold, and pain, small cuts or wounds are missed. These cuts may become infected, and lead to ulcers and gangrene requiring amputations.

8) EYE INVOLVEMENT 

A lot of people go blind around the world due to damage to their eyes with high blood sugars. This is why a yearly dilated eye exam is recommended for all people with type 2 diabetes even if they don’t have symptoms. Uncontrolled blood sugars can affect the retina. The symptoms may include

  • Blurred vision
  • Light flashes and floaters
  • Dark spots
  • Problems in night vision

A HEALTHY LIFESTYLE IS A KEY TO PREVENTING PROBLEMS RELATED TO DIABETES

  • Compliance with medicines and regular follow-ups
  • 3 monthly monitoring of HbA1c level, fasting, postprandial blood sugar levels, complete hemogram, thyroid function test, lipid profile, urine albumin-creatinine ratio, vitamin B12, and folic acid.
  • Healthy dietary habits (low carbohydrates, high protein diet)
  • Physical activity (30-minute walk 5 days a week)
  • Smoking cessation
  • Maintenance of BP<140/90 and Cholesterol <200mg/dl
  • Maintenance of appropriate weight
  • Diabetic foot care awareness
  • Follow up with cardiologist every 3 months and ophthalmologist yearly

The root cause of all her symptoms was high blood sugar levels. She was suggested to either start dapagliflozin 10mg orally once daily with Vildomet or start metformin 1000mg twice daily with injection of liraglutide 0.6mg up to 1.2mg subcutaneous once daily or start long-acting insulin once daily starting at 10 units subcutaneous every night. We also advised her to continue her vitamins and added pregabalin 75mg twice daily for the burning sensation in her feet. We directed her to take losartan once daily for high blood pressure and kidney protection and added atorvastatin 40mg once daily for increased cholesterol levels. She was counseled on the above-mentioned healthy lifestyle guidelines. We recommended she monitor her blood sugar at home twice daily. We hope to see an improvement in two weeks when she comes for a follow-up.

 

Dr Lubna Mirza and NRHS Associates
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