DM II Med question....

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Hi all....I have a question about a diabetic pt I saw today and wanted to get some feedback...

Pt is in her 50s, DM II, full metabolic syndrome...a1c 3 months ago was 7.4 and she has been on low-dose metformin (only low-dose bc not tolerating higher doses d/t diarrhea), Januvia, and glyburide. When she came in today, her BS was 250 and she said her home BS seemed to be going up and hanging out at 250 all the time...

Rechecked her a1c today and it was 8.4. I reviewed her case with my supervising physician, and he suggested we start her on Victoza, but keep everything else the same. I wasn't sure about combining the Victoza w/Januvia in particular, and in doing some research, I've found some things that say to not put a DPP4 inhibitor and an incretic mimetic together....

Any input? I'm a new FNP, and I love working w/diabetic pts, I just need more practice it seems like w/more uncontrolled diabetes...plus it seems like as with this patient, a lof of the lifestyle change information is not taken seriously even though I stress diet and exercise, etc every visit...

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Also, FYI, I haven't changed any of her meds yet--got her labs back this evening after patients and have her scheduled to come back next week to discuss changes in her meds...

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Specializes in Family Practice, Primary Care.

How long did she try the max metformin? The diarrhea typically goes away by 2 weeks. That could be an option if she didn't give it a long try.

Otherwise, I'd add Lantus honestly. Start at 10 units at night and titrate up and emphasize diet/exercise. Emphasize lantus is more like an "antibiotic" for her pancreas and once her A1C comes down her pancreas may pick back up. I am not a fan of using all the new fancy DM meds when insulin WORKS. (I've done 35 weeks of a DM clinical rotation)

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Specializes in Adult Internal Medicine.

I would pretty strongly consider Lantus. How long has seen been a diabetic?

I know it doesn't help much with your original question but given the presentation, I feel that insulin is the best option. I might try upping her metformin again too and see if she can tolerate it.

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I agree with the above post. Sounds like she needs insulin.One you started combining and adding on stuff , it may just be easier to go on insulin.. She could always get off of it. If shes doing the things she needs too.

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Thanks so much for the advice....I have to say adding on multiple multiple DM meds makes me nervous too, and Lantus would be enticing...I ended up giving her some in the office that day w/her glucose being 250 and she about wasn't up for that....and I've counseled and spent so much time w/education, etc, and it's like she's so unresponsive.....frustrating.....So stupid question....if I go w/Lantus, I can keep her on the metformin, but do I keep her on the glyburide? I'd stop the Januvia....She's been on metformin for years with dosage changes and is tolerating mild diarrhea with the low-dose.....

I'd love love love to do a DM rotation of some kind....I've been looking into specific diabetic education programs but hard to find....

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Increasing A1C on triple therapy begs for more investigation. Is she actually taking them meds? Has she made some appropriate changes to activity and nutrition? Has she gone for outpatient diabetic education?

I work exclusively with diabetes and would consider glucose toxicity in this pt. If she would agree to it, I would suggest a short period of insulin use, education, lifestyle changes, and serious investigation of what she's eating. If she responds well to insulin and gives her pancreas a bit of a break for a few weeks, she may find she can go back to combination of orals with better success.

Januvia and Byetta/Victoza are not prescribed together since they have such similar effect. The injectables are much more effective...but they're injectable. Very easy to use, impossible to screw up, and will not cause hypoglycemia. I would try Metformin ER, Byetta, and Amaryl after she's used insulins to bring CBGs under control for a couple of weeks while attending education for food & activity. That combination of meds comes at diabetes from the perspective of insulin resistance, the need for greater insulin production, and the metabolic disarray of the pancreas in appropriately secreting glucagon even after carbs are ingested.

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Increasing A1C on triple therapy begs for more investigation. Is she actually taking them meds? Has she made some appropriate changes to activity and nutrition? Has she gone for outpatient diabetic education?

I work exclusively with diabetes and would consider glucose toxicity in this pt. If she would agree to it, I would suggest a short period of insulin use, education, lifestyle changes, and serious investigation of what she's eating. If she responds well to insulin and gives her pancreas a bit of a break for a few weeks, she may find she can go back to combination of orals with better success.

Januvia and Byetta/Victoza are not prescribed together since they have such similar effect. The injectables are much more effective...but they're injectable. Very easy to use, impossible to screw up, and will not cause hypoglycemia. I would try Metformin ER, Byetta, and Amaryl after she's used insulins to bring CBGs under control for a couple of weeks while attending education for food & activity. That combination of meds comes at diabetes from the perspective of insulin resistance, the need for greater insulin production, and the metabolic disarray of the pancreas in appropriately secreting glucagon even after carbs are ingested.

Thanks so much.....wow, I wish I was you right now! You sound like a superstar! As a new FNP, I feel kind of overwhelmed sometimes trying to juggle these meds and the patho, and education.....she's such an unmotivated pt...states she is taking the meds as rx'd, but has no interest in doing any kind of lifestyle modification...We talked quite a bit, so I guess you never know some of the info might be seeping in to plant a seed or two....And I swear, when I try to get ANY of my patients to sign up for an education class, no one wants to...no one.....

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Is she depressed? I certainly would be in her shoes. at least at the beginning. Does she have an explanation for her refusal to take care of herself? Perhaps there is family history of that behavior? has she seen persons "take care of themselves" and had no apparent improvement?

Thanks so much.....wow, I wish I was you right now! You sound like a superstar! As a new FNP, I feel kind of overwhelmed sometimes trying to juggle these meds and the patho, and education.....she's such an unmotivated pt...states she is taking the meds as rx'd, but has no interest in doing any kind of lifestyle modification...We talked quite a bit, so I guess you never know some of the info might be seeping in to plant a seed or two....And I swear, when I try to get ANY of my patients to sign up for an education class, no one wants to...no one.....
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So...my patient came back to see me today and it was great....her daughter came with her and I spent about 30 minutes or so going through more detailed info on the diet, we came up w/a workout plan....she said after she left the office last time it kind of hit her later that her a1c was up and her diabetes was getting out of control...So she said she brought her daughter to help her take notes, and the two of them were going to start working out together, etc....it was great!

After discussing more w/my supervising physician, I ended up decreasing her glyburide, stopping the Januvia, and starting Victoza....I do see the benefits of just putting her on Lantus, but my doc was pretty set on Victoza, and it could help her lose some weight, so I figured it was worth a try.....I'll keep you all updated...

I reallly appreciate all of the advice and info....you all are great....

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Keep us updated. I enjoy reading FNP post. Im in psych so this is good info to know.

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