Interactive diabetes case 7: Management of diabetes in a 72-year-old patient with type 2 diabetes, GI bleeding, and multiple other medical problems

CASE — A 72-year-old man returns to see you in your office following a recent hospital admission for gastrointestinal (GI) bleeding. The patient is treated with warfarin and clopidogrel for cardiac indications. He has had recurrent GI bleeding requiring intermittent blood transfusions for approximately six months. The site of the bleeding has eluded diagnosis despite upper GI endoscopy, colonoscopy, and capsule enteroscopy. The patient has had type 2 diabetes for 23 years and has been on insulin for 11 years. His diabetes is complicated by retinopathy, peripheral neuropathy, and chronic kidney disease. The patient has rheumatic heart disease, coronary artery disease, congestive heart failure, and atrial fibrillation. He has had mitral and aortic valve replacements and recent placement of a stent in the left anterior descending artery. The estimated left ventricular ejection fraction is 26 percent. On the day of discharge from the hospital, the blood urea nitrogen (BUN) was 66 mg/dL, creatinine 2.2 mg/dL, international normalized ratio (INR) 2.4, and glycated hemoglobin (A1C) 5.40 percent. His medications include NPH insulin 58 units every morning and 24 units every day at bedtime. He is also on furosemide 120 mg twice a day, potassium chloride 20 mEq twice a day, spironolactone 50 mg once a day, metolazone 5 mg every other day, esomeprazole 40 mg a day, warfarin 4 mg a day, and clopidogrel 75 mg a day. He has been eating regularly and checking his blood glucose level at home since discharge. The glucose values before breakfast have been 131 to 152 mg /dL (7.3 to 8.4 mmol/L), and those before supper have been 143 to 197 mg/dL (7.9 to 10.9 mmol/L).

How would you manage the patient's diabetes at this time?

●Reduce insulin doses by 50 percent because the A1C indicates excessively tight management in this patient, in whom hypoglycemia is of more than the usual concern because of his cardiovascular disease. (See "Interactive diabetes case 7: Management of diabetes in a 72-year-old patient with type 2 diabetes, GI bleeding, and multiple other medical problems – A1".)

●Stop insulin to avert hypoglycemia in this patient, in whom hypoglycemia is of more than the usual concern because of his cardiovascular disease, and begin glyburide 10 mg before breakfast and 10 mg before supper to provide more gentle control of the diabetes. (See "Interactive diabetes case 7: Management of diabetes in a 72-year-old patient with type 2 diabetes, GI bleeding, and multiple other medical problems – A2".)

●Stop insulin to avert hypoglycemia in this patient, in whom hypoglycemia is of more than the usual concern because of his cardiovascular disease, and begin metformin 1000 mg before breakfast and supper to manage diabetes without the risk of hypoglycemia. (See "Interactive diabetes case 7: Management of diabetes in a 72-year-old patient with type 2 diabetes, GI bleeding, and multiple other medical problems – A3".)

●Increase the dose of NPH insulin before breakfast to 64 units to manage the hyperglycemia before supper, increase the dose of NPH insulin at bedtime to 28 units to manage the hyperglycemia before breakfast, and ignore the A1C level. (See "Interactive diabetes case 7: Management of diabetes in a 72-year-old patient with type 2 diabetes, GI bleeding, and multiple other medical problems – A4".)