Interactive diabetes case 14: A 41-year-old patient with type 2 diabetes and hypertriglyceridemia – A3

ANSWER — Correct.

This patient is at risk for acute pancreatitis. He also has uncontrolled diabetes. His low-density lipoprotein (LDL) cholesterol is unknown. He needs an approach that addresses each of these issues in an iterative manner.

The patient returns in one month as planned. He has adhered to the diet at home but not always in restaurants. He has fish only once a week and a 16 oz steak at least once a week. He is not willing to avoid his favorite restaurant, which is the focus of his social life.

He has seen the registered dietitian, who has reinforced your advice; discussed strategies for ordering in restaurants; given more detailed instructions about a low saturated fat, low-cholesterol diet; and discussed the importance of controlling portions at meals including those of carbohydrates. A follow-up meeting has been scheduled.

His glucose diary reveals fasting values in the 180 to 210 mg/dL (9.99 to 11.66 mmol/L) range, values before supper in the 170 to 210 mg/dL (9.44 to 11.66 mmol/L) range, and values at bedtime (only two hours after supper when he eats in the restaurant) in the 230 to 315 mg/dL (12.77 to 17.49 mmol/L) range. He has not lost weight.

His fasting laboratory values a few days before the visit are as follows: glucose 259 mg/dL (14.38 mmol/L), total cholesterol 217 mg/dL, triglycerides 604 mg/dL, and high-density lipoprotein (HDL) cholesterol 34 mg/dL. The LDL cholesterol was not calculated, because the triglyceride level is again above 400 mg/dL.

You conclude that the patient's triglyceride level has responded to dietary intervention but is still too high and that the diabetes remains uncontrolled. You feel that the dietary component has been addressed as well as possible and that the patient now needs additional pharmacologic treatment of the diabetes.

What is your assessment and plan?

●Because of his lifestyle, you advise him to take lispro insulin before supper and glargine insulin at bedtime. He refuses to take more than one shot of insulin a day, even after review of the rationale for this recommendation, saying that his older brother, who also has diabetes, takes only one shot of insulin a day.

You start him on an insulin preparation containing a fixed ratio of an intermediate-acting insulin and a very short-acting insulin, Humalog Mix 75/25 (75 percent insulin lispro protamine suspension and 25 percent lispro injection), 20 units daily before supper. (See "Interactive diabetes case 14: A 41-year-old patient with type 2 diabetes and hypertriglyceridemia – B1".)

●Because of his lifestyle, you advise him to take lispro insulin before supper and glargine insulin at bedtime. He refuses to take more than one shot of insulin a day, even after review of the rationale for this recommendation, saying that his older brother, who also has diabetes, takes only one shot of insulin a day. You explain the rationale again and start him on lispro insulin 6 units before supper and glargine insulin 14 units at bedtime. (See "Interactive diabetes case 14: A 41-year-old patient with type 2 diabetes and hypertriglyceridemia – B2".)

●You prescribe a fibric acid derivative, fenofibrate 145 mg every morning. You advise him again to limit his carbohydrates to control the diabetes. (See "Interactive diabetes case 14: A 41-year-old patient with type 2 diabetes and hypertriglyceridemia – B3".)