Case Study

Workshop
Four Season Hotel, 17th February
2012

Dicky L. Tahapary
Division of Metabolism and Endocrinology
Department of Internal Medicine
Faculty of Medicine University of Indonesia dr.Cipto Mangunkusumo
Hospital

Case Study 1
46-year-old female
Had diabetes since 15 years ago
maintain good glycemic control
Diet + Exercise + Metformin 2x850mg

Slightly overweight
Had hypertension since 15 years ago

Case Study 1
Family History
Mother : Diabetes and CAD
Father : Hypertension and died of MI
at the age of 46
Social History
Secretary
Follows dietary and exercise program

Case Study 1
Physical Examination
Weight 72kg, Height 165cm
Waist Circumference 98cm
Blood Pressure 155/85mmHg

Laboratory
A1c 7.4%
TC 215 mg/dL, HDL-C 29 mg/dL, LDL-C
118 mg/dL, TG 290 mg/dL

Question 1

What are the problems of the patient?

Question 2
What is the risk stratification for
this patient
1. Low Risk
2. Moderate Risk
3. High Risk
4. Very High Risk
5. Need further examination

Question 3

What treatment regimen would

you recommend to this patient?

Next Case

Case Study 2
Mr.B, 65-year-old

Easy fatigability since 6

months ago
He also reported the presence of unusual thirst, extreme
hunger and unusual weight loss.
He also reported increase micturition at night.
He had no history of previous illnesses.

His mother :
T2DM, Hypertension, Coronary Artery Disease

His random blood glucose : 244mg/dL

He went to doctor and underwent some tests
BP was 130/80 mmHg, BMI 26 kg/m2
A1c was 8.6%
Liver and renal function were within normal
limits

The doctor advised :

Lifestyle modification and Metformin 500
mg OD

For the last 6 months, the doctor had increased the dose
of metformin for some times.
His last dose of metformin was 500 mg TID
From further examinations, he had mild NPDR and microalbuminuria

Laboratory Results
Hb

12 mg/dL

WBC

6.000 /uL

Platelet

250.000 /uL

SGOT/PT

19/24

Ur/Cr

30/1.1

FBG/PPBG

144/210 mg/dL

HbA1C

8.1 %

TC/TG/HDL/LDL

242/105/52/169

Albuminuria

240 mg

Question 1
What next step would you recommend to intensify the
therapy in this patient?

1. Increase the dose of current anti diabetic agent

2. Addition of second drug from different class, which
one?
3. Addition of insulin, which one?
4. Switch to insulin, which one?
5. Others

Last week, he was once brought to the

emergency unit due to episode of hypoglycemia.
He took glybenclamide 5mg twice daily as it was
suggested by his neighbours

Ms. W, 64-year old with

1. Uncontrolled T2DM with hypoglycemia
history
2. Obesity
3. Dyslipidemia
On Metformin 1000 mg BID

Question 2
What should be taken into consideration in drug
selection for the intensification of diabetes therapy?

1. Efficacy
2. Risk of hypoglycemia
3. Risk of weight gain
4. Different mechanism of action
5. All of above

Question 3
Taking into account the matters mentioned
before and also the patients overall clinical
condition, what agent will you add to this
patients treatment regiment?
1. Sulfonylurea
2. Glitazone
3. DPP-IV Inhibitor
4. Alpha-glucosidase inhibitor
5. Others

Next Case

Case Study 3

63-year-old woman was diagnosed with type 2 diabetes

mellitus 8 months ago, currently receiving Metformin
500mg TID and Glimepiride 2mg OD
BMI 30kg/m2, HbA1c 7.0%
She had no diabetic complications.

Question 1
Has the patient achieved good
glycemic control?
1.Yes
2.No
3.Not sure
4.Ask the expert

Case Study 3

Question 2
Has the patient achieved good glycemic control?
1. Yes
2. No
3. Not sure
4. Ask the expert

Question 3
Would you recommend changes on treatment
regimen?
1. Yes
2. No
3. Not sure
4. Ask the expert

Case Study 3

Case Study 3

Final Question
It is recommended that any strategy aimed at
controlling the glycemic disorders associated with
type 2 diabetes, and limiting the risk of
complications, should target the following :
1.HbA1c
2.Fasting plasma glucose (FPG)
3.Postprandial plasma glucose (PPG)
4.Markers of glycemic variability such as
MAGE
5.All of above

THANK YOU