What is the best course of action for a 53-year-old female patient with poorly controlled diabetes (HbA1c of 12.0), hypertension, hyperlipidemia, coronary artery disease (CAD) with preserved ejection fraction (EF), vision impairment, and spinal stenosis, who recently had pneumonia and is now showing signs of early kidney dysfunction and elevated liver enzymes?

From the Guidelines

This 53-year-old female with multiple comorbidities requires immediate intervention for her uncontrolled diabetes, and I strongly recommend referral to an endocrinologist for comprehensive diabetes management. Her HbA1c of 12.0 indicates dangerously poor glycemic control, though it has improved slightly to 8.6 as of October 2024 1. According to the American College of Physicians guidance statement, clinicians should personalize goals for glycemic control in patients with type 2 diabetes, taking into account benefits and harms of pharmacotherapy, patients' preferences, general health, and life expectancy 1.

Key Recommendations

• Referral to an endocrinologist for comprehensive diabetes management to achieve better glycemic control.
• Continuous glucose monitoring system to help manage her diabetes, given her visual impairment and medication administration errors.
• Insulin pump consideration to provide more consistent dosing and reduce the risk of hypoglycemia.
• Lifestyle modifications, including a low-fat diet, reduced Tylenol use, and avoidance of alcohol, to manage her elevated liver enzymes.
• Statin therapy optimization and dietary counseling to reduce trans fat intake and increase healthy fats for her elevated LDL cholesterol.
• ACE inhibitor or ARB therapy to manage her early kidney dysfunction, as indicated by the elevated albumin/creatinine ratio.
• Comprehensive medication review to ensure all comorbidities are adequately managed, with special attention to her diabetes regimen, which may require adjustment of insulin type, dosing schedule, and potentially adding oral agents like metformin or SGLT2 inhibitors if not contraindicated by her kidney function 1.

Additional Considerations

• The patient's visual impairment and medication administration errors highlight the need for a continuous glucose monitoring system and consideration of an insulin pump to provide more consistent dosing and reduce the risk of hypoglycemia.
• The elevated albumin/creatinine ratio indicates early kidney dysfunction, requiring ACE inhibitor or ARB therapy if not already prescribed.
• The patient's daughter's needle stick incident warrants hepatitis testing for the daughter rather than the patient, as the patient's hepatitis panel is normal.
• A comprehensive medication review is essential to ensure all comorbidities are adequately managed, with special attention to her diabetes regimen, which likely needs adjustment of insulin type, dosing schedule, and potentially adding oral agents like metformin or SGLT2 inhibitors if not contraindicated by her kidney function.

From the FDA Drug Label

The time of occurrence of hypoglycemia depends on the action profile of the insulins used and may, therefore, change when the treatment regimen or timing of dosing is changed In patients being switched from other intermediate or long-acting insulin preparations to once- or twice-daily LEVEMIR, dosages can be prescribed on a unit-to-unit basis; however, as with all insulin preparations, dose and timing of administration may need to be adjusted to reduce the risk of hypoglycemia Renal Impairment As with other insulins, the requirements for LEVEMIR may need to be adjusted in patients with renal impairment Hepatic Impairment As with other insulins, the requirements for LEVEMIR may need to be adjusted in patients with hepatic impairment

The patient's current diabetes management is concerning, with a reported HbA1c of 12.0, indicating poorly controlled diabetes. The patient's renal impairment and hepatic impairment may require adjustments to their insulin regimen.

• The patient's elevated albumin/creatinine ratio is an early sign of kidney dysfunction, which may impact their insulin requirements.
• The patient's elevated liver enzymes may also require adjustments to their insulin regimen. Given the patient's complex medical history and current condition, it is essential to closely monitor their blood sugar levels and adjust their insulin dosage as needed to achieve tighter glycemic control. The patient should be referred to an endocrinologist to help manage their diabetes and adjust their insulin regimen accordingly 2.

From the Research

Patient's Diabetes Management

• The patient's HbA1c level is 12.0, indicating poorly controlled diabetes 3.
• The decision to refer the patient to an endocrinologist is warranted to achieve better glycemic control 3.
• Studies suggest that insulin may not be the preferred treatment for HbA1c >9% and that other therapeutic approaches, such as metformin, incretin-based treatments, and SGLT2 inhibitors, may be effective in achieving glycemic control 4.

Liver Enzymes and Hyperlipidemic Profile

• The patient's liver enzymes are elevated, which may be associated with hyperlipidemic profile in type 2 diabetes patients 5.
• ALT and GGT showed significant positive correlation with fasting glucose, post-prandial glucose, HbA1c, TC, Tg, LDL-C, and GGT at p>0.05 5.
• Routine screening of ALT and GGT in type 2 diabetes patients may assist in early detection of liver abnormalities and arrest the progress of disease 5.

HbA1c Measurement and Interpretation

• HbA1c should not be interpreted in isolation, and measurement accuracy and other parameters, including treatment goals and comorbidities, need to be considered 6.
• Non-glycaemic variables can affect HbA1c, but the clinical implications are generally irrelevant, and a small number of non-glycaemic variables have clinically significant effects 7.
• Alternative biomarkers should be considered instead of, or in addition to, HbA1c in certain clinical scenarios 7.

Treatment and Management

• The patient's medication was refilled during the office visit, and the patient was advised to decrease bad trans fat in diet and increase good saturated fat in diet.
• The patient was also advised to decrease Tylenol and alcohol intake and reduce fat in diet to manage elevated liver enzymes.