What is the clinical significance of a 44-year-old female with type 2 diabetes mellitus (DM) presenting with hyponatremia, hypokalemia, hypochloremia, metabolic acidosis, impaired renal function, and hyperglycemia?

From the Guidelines

The patient's current diabetes management regimen appears to be effective, and she should continue with her current treatment plan, prioritizing regular follow-up labs every 3-6 months to monitor glucose control, acid-base status, and kidney function, as recommended by the American Diabetes Association standards of medical care in diabetes 1. The patient's lab results show generally stable values with a few notable findings. Her glucose levels have improved significantly over the past year, now at 85 mg/dL, which is within the normal range (70-99 mg/dL), compared to previous elevated values of 101-164 mg/dL. This indicates good glycemic control of her type 2 diabetes. Some key points to consider in her management include:

• The importance of maintaining a healthy weight, as excess weight can contribute to insulin resistance, a key factor in type 2 diabetes management 1.
• Regular physical activity, which can help improve insulin sensitivity and overall health 1.
• Monitoring for potential complications of diabetes, such as kidney disease, which can be assessed through regular measurements of eGFR, as well as screening for other comorbidities like hypertension and dyslipidemia 1. There is a persistent mild metabolic acidosis with CO2 levels consistently below normal range (21 mmol/L vs normal 22-32 mmol/L) in recent measurements. Her creatinine is slightly low at 0.58 mg/dL, but kidney function appears excellent with eGFR consistently above 100 mL/min. Liver function tests are normal to mildly decreased. The mild metabolic acidosis should be monitored but doesn't require immediate intervention given its stability. The improved glucose control suggests her diabetes treatment regimen is working well, though maintaining this control is important for preventing long-term complications of diabetes, as highlighted in the 2021 standards of medical care in diabetes 1.

From the Research

Patient Profile

• Age: 44 years
• Gender: Female
• Diagnosis: Type 2 Diabetes Mellitus (DM)
• Laboratory results:
  • Sodium: 137 mmol/L (within normal range)
  • Potassium: 4.0 mmol/L (within normal range)
  • Chloride: 105 mmol/L (within normal range)
  • CO2: 21 mmol/L (low)
  • Anion Gap: 11 (within normal range)
  • Glucose: 85 mg/dL (within normal range)
  • BUN: 8 mg/dL (within normal range)
  • Creatinine: 0.58 mg/dL (low)
  • eGFR: 115 mL/min/1.73m2 (within normal range)
  • BUN/Creatinine Ratio: 13.8 (within normal range)
  • Calcium: 9.0 mg/dL (within normal range)
  • AST (SGOT): 9 unit/L (low)
  • ALT (SGPT): 9 unit/L (within normal range)
  • Alkaline Phosphatase: 46 unit/L (within normal range)
  • Total Protein: 7.1 g/dL (within normal range)
  • Albumin: 4.0 g/dL (within normal range)
  • Total Bilirubin: 0.6 mg/dL (within normal range)

Treatment Options

• According to the study 2, metformin is the first-line treatment for patients with Type 2 diabetes.
• Additional therapy is dependent on multiple patient-specific factors, including cardiovascular risks, risk of hypoglycemia, metabolic changes, and cost.
• The study 3 compared the effectiveness of SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, and sulfonylureas on risk of major adverse cardiovascular events.
• The study 4 found that DPP-4 inhibitors were associated with a lower risk of hypoglycemia and weight gain compared to sulfonylureas.
• The study 5 found that the combination of DPP-4 inhibitors with metformin was associated with a decreased risk for major adverse cardiovascular events and all-cause mortality compared to the combination of sulfonylureas with metformin.
• The study 6 found that DPP-4 inhibitors were associated with a smaller decline in HbA1c, weight loss, and a lower incidence of hypoglycemia compared to sulfonylureas.

Considerations

• The patient's laboratory results show that she has well-controlled diabetes, with a glucose level of 85 mg/dL.
• The patient's eGFR is within normal range, indicating that she does not have kidney disease.
• The patient's cardiovascular risk factors are not specified, but the studies suggest that DPP-4 inhibitors may be a good option for patients with Type 2 diabetes who are at risk for cardiovascular events.
• The patient's risk of hypoglycemia is not specified, but the studies suggest that DPP-4 inhibitors may be a good option for patients who are at risk for hypoglycemia.