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Patient Background George is a 54 year-old Caucasian man with diabetes and asthma. Ho teaches history at a local high school in New Jersey. He was diagnosed with type 2 diabetes on blood tests performed when he applied for life insurance at age 51. At the time, he was obese, weighing 215 pounds at 5 feet, 10 inches height (BMI = 31). He stopped smoking at age 46 and he does not consume alcohol. George lost 20 pounds with a strict diet and daily exercise and started metformin, which was titrated up to 1000 mg twice-daily. His glucose levels improved and his A1c declined from 7.2% to 6.2% within 4 months. At age 52 glimepiride (Amary16) was added at a dose of 2 mg daily due to a rise in A1c to 7.3%. His A1c rose to 6.6%, and he gained 5 pounds. George controls his asthma with inhaled medications, including fluticasone propionate and salmeterol inhalation powder (Advaire) 250/50 mcg, and montelukast sodium (Singulairf) 10 mg daily. Last year George’s asthma worsened. In addition to inhaled medications, he has intermittently required Prednisone in doses up to 40 mg daily. Exercise has been less regular and he has gained a further 10 pounds in weight. HbAlc has risen to 8.5%, corresponding to an overall average blood glucose of 220 mg/dL. Age: 54 Weight: 215 lbs. Height: 5’10 BMI: 31 Blood Glucose Last A1C: 8.5% (overall average 220 mg/dL) Fasting: 94-135 mg/dL Post-breakfast: 250-340 mg/dL Pre-lunch: 200-300 mg/dL Post-lunch: 220-310 mg/dL Pre-dinner: 125-150 mg/dL Bedtime: 164-234 mg/dL Lipid Profile Total: 194 mg/dL LDL: 120 mg/dL HDL: 31 mg/dL Triglycerides: 210 Kidney Profile Creatinine: 1.2 mg/dL Microalbuminuria: Liver Function ALT: 27 AST: 39 Blood Pressure Normal: 135/90 mmHg Cardiovascular profile High cholesterol, low HDL, no history of chest pain or known CHD Eye Exam Background diabetic retinopathy Foot Exam n/a Compliance with meal plan? Less compliant with diabetes meal plan than he used to be Compliance with exercise plan? Limited activity. For blood glucose: Metformin 1000 mg bid Glimepiride 2 mg qd For other conditions: prednisone (Sterapredo) 40 mg ad fluticasone propionate and salmeterol (Advair Diskus) 250/50 mcg ad montelukast sodium (Singulaire) 10 mg ad 1) What is contributing to George’s increase in his HgbA1C? 1 2) How does Glimepiride work? What patient teaching needs to be done for someone on this medication? 3) The doctor tells George he is going to start him on basal-bolus insulin dosing. George asks you what that means. How do you explain that to him? 2 4) George’s prescription reads: Lantus insulin 10 units subcutaneously, daily; insulin aspart (Novolog) 5 units TID with meals. What teaching does George need with these medications? What is the onset, peak and duration for each?
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