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Diabetes Mellitus Type 2

Clinical Care

Primary Care Physician

Dr. Emmett told Alvin that he had diabetes based on his elevated random glucose and the presence of symptoms. The American Diabetes Association standard for diagnosing diabetes is a fasting blood glucose above 125 mg/dL or a random blood glucose of 200 mg/dL or above with symptoms of diabetes, either criteria repeated on a second day. The elevated HbA1c result indicated that Alvin's average blood glucose for the prior two to three months was in excess of 400 mg/dL. This level of blood glucose accounted for the increase in urination and the weight loss that Alvin had experienced. The four classic symptoms of diabetes are:

• polyuria (excessive urination),
• polyphagia (excessive hunger),
• polydipsia (excessive thirst) and
• unexplained weight loss.

Common symptoms are fatigue, blurred vision, frequent infections, poor wound healing, dry, itchy skin and numbness and tingling in hands, legs and feet. Of the common symptoms, Alvin had the numbness in his fingertips, a burning sensation in his feet and blurred vision. His blurred vision was often worse after lunch on workdays, caused by his drinking a "Big Gulp" regular soda with his lunch, and thus increasing his glucose load in the afternoons.

Dr. Emmett gave Alvin a referral for a dilated eye exam in his health plan's eye care center. He also suggested that Alvin make an appointment with a dentist to be assessed for periodontal disease, another common problem for patients with diabetes.

Dr. Emmett performed a Carville foot exam on Alvin, checking for both microvascular and neuropathic problems. The exam was normal, except for calluses on his big toes. Dr. Emmett advised to wear shoes with larger toe boxes. Alvin did discuss his fears with Dr. Emmett about diabetes leading to amputations, since this had been a major problem in his mother's condition.

Dr. Emmett used the opportunity to discuss blood glucose management through monitoring, medical nutrition therapy, and medication. He instructed Alvin to contact the Diabetes Center to sign up for classes on diabetes self-management, which were a benefit of Alvin's health plan. In addition, he gave Alvin two prescriptions: one for a blood glucose meter, instructing Alvin to check his blood sugar before meals, and one for an oral diabetes agent.

In Alvin's case, Dr. Emmett prescribed Amaryl® (glimepiride), 4 mg. a day. Amaryl® is in the class of drugs called sulfonureas, which stimulate the islet cells in the pancreas to produce more insulin. Other classes of oral diabetes agents are:

• Biguanides:  decrease the release of glucose by the liver, and makes other cells more sensitive to insulin.
• Thiazolidinediones (TZDs):  increase cellular sensitivity to insulin and decreases the release of glucose by the liver.
• Meglitinides:  stimulate the pancreas to release insulin over a shorter period of time (after meals).
• Alpha glucosidase inhibitors:  slow the absorption of carbohydrates in the intestine.

These oral diabetes agents can be given singly or in combinations.

Dr. Emmett scheduled Alvin back for a visit in one month.