Woman With Elevated A1C Who Has Had a Stroke

Sue Jones, 79 years old, has had type 2 diabetes mellitus for 15 years. She is homebound after a recent stroke and now requires assistance with most of her activities. She has a daytime sitter and a weekly visiting nurse; her family provides care in the evenings and on weekends. The family has moderate means and would like to keep her at home. Sue can communicate effectively: she recognizes all of her family members and you, as her physician.

Her most recent lab tests showed an HbA1c of 9.6; a random blood sugar of 450; triglycerides, 350 mg/dL; HDL, 40; LDL, 110 (calculated); total cholesterol, 220; and non-HDL,180.

Some of her medications were stopped when she was discharged from the hospital 3 weeks ago. She now only takes metformin (2000 mg/d) for her diabetes and no medications for her lipids.

Would you consider more aggressive treatment of her elevated HbA1c? If so, why-and with what medications? What goals would you have for her A1C? Would you do anything to treat her lipids?

Click here for Dr Shahady’s discussion of options.

Discussion
I would treat this patient more aggressively. Although we usually think of long-term complications as the main reason to control hyperglycemia-some significant short-term reasons exist.

Sue may not live 10 more years, but the quality of her remaining years is important. With her level of hyperglycemia, she will have significant polyuria and will be at increased risk of bedwetting and other accidents that will make it difficult for family and others to provide care. The smell of urine is offensive to family members and also to the patient. The skin on a wet bottom can excoriate and create a breeding ground for infection and decubitus ulcers. Moreover, weight loss, dehydration, pre-renal azotemia, visual changes, and a hyperosmolar state are more likely if blood sugar is not better controlled.

I would measure Sue’s glomerular filtration rate to help me with dosage decisions on medications. Her GFR may already be lower than 60 mL/min, and I may want to consider discontinuing the metformin.

I would consider basal insulin to try to reach an A1C goal of 7.5 to 8.

The ACCORD study provided us with good information about individualizing A1C goals for patients. I use the following information to guide setting an A1C goal.
1. Psychosocial level of depression, support, resources and motivation. Sue has good support and resources. 
2. Risk of hypoglycemia . . . prior hypoglycemia, lack of recognition of early hypoglycemia, and autonomic neuropathy. Sue does not seem to have this risk.
3. Level of frailty (not age alone). Some 80-year-olds are playing tennis or riding a bike daily. Sue’s stroke and disability make her more frail.
4. Any other comorbidity. Sue has no other chronic disease.
5. Presence of cardiovascular disease. Sue suffered a CVA so is more likely to have another CV event if she becomes hypoglycemic or remains with significant hyperglycemia and dyslipidemia.¹ I do not want to push her A1C below 7 but would like to reach a level of A1C and glucose that takes into account her comfort and the comfort of her care givers. The chances of compromised renal function are increased, so the dosage of all her medications will need to be adjusted. This may also be true with insulin, but insulin dosage can be controlled. I would opt for one of the newer basal insulins to see if a more reasonable blood sugar and A1C level can be obtained.

The question about treating her lipids is more complex. Her LDL is not that high-but it is calculated. If her hyperglycemia is treated, triglyceride levels will decrease and the LDL will rise. But a non-HDL of 180 (with a target of 130) is problematic. Non-HDL is a better predictor of CV events when the triglyceride levels are over 200.² There will be some rise in the HDL of 40 with better treatment of the diabetes.

The real question is what is the short-term value of treating her dyslipidemia? Sue’s life expectancy may not justify a 10- to 20-year risk reduction, but will treatment with a low-dose statin help decrease short-term mortality and morbidity? I think it will. Statins not only lower LDL levels, but they also stabilize plaque and decrease inflammation (pleiotropic effects). Plaque stabilization and a decrease in the inflammatory environment will decrease the chances of plaque rupture, thrombosis, and a CV event (eg, another stroke).³

References
1. Ismail-Beigi F, Moghissi E, Tiktin M, et al. Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials. Ann Intern Med. 2011;154:554-559.
2. Boekholdt SM, Arsenault BJ, Mora S, et al. Association of LDL cholesterol, non-HDL cholesterol, and apolipoprotein B Levels with risk of cardiovascular events among patients treated with statins. JAMA. 2012;307:1302-1309.
3. Robinson JG, Smith B, Maheshwari N, Schrott H. Pleiotropic effects of statins: benefit beyond cholesterol reduction? A meta-regression analysis. J Am Coll Cardiol. 2005;46:1855–1862.