A 44-year-old man with type 2 diabetes was recently hospitalized for an acute
exacerbation of pancreatitis. This was his seventh admission for the condition
within the past several years. Although imaging studies revealed no calcifications,
the hospitalist suspected that acute relapsing pancreatitis was evolving
into chronic pancreatitis.
The patient now comes to your office for evaluation.
The pancreatitis is alcohol-related; the patient has a decades-long history
of alcohol abuse. He consumes about 8 oz daily and drinks more during
binges (one of which occurred just before his most recent hospitalization).
He has had diabetes for at least 3 years and takes glyburide, 10 mg bid.
His glucose control has been problematic at best; he has performed home
monitoring sporadically and reports that glucose levels have ranged between
200 and 300 mg/dL. The patient says that the glyburide seemed to work better
when he first began therapy. He was given insulin in the hospital; however,
glyburide was prescribed at discharge.
Studies performed before his visit disclosed the following values: bilirubin,
1.2 mg/dL; creatinine, 1 mg/dL; fasting blood glucose, 212 mg/dL;
and glycosylated hemoglobin A (HbA1c), 9.9%. Elevated transaminase levels
(alanine aminotransferase, 300 U/L) prompted a test for hepatitis C virus (HCV)
infection, which was positive.
The patient appears older than he is, and his weight is slightly less than
normal for his age and height. However, vital signs are normal, there is no
jaundice or spider angiomata, bowel sounds are good, and his abdomen is nontender
and without hepatosplenomegaly.
In addition to dietary measures and alcohol abstinence, which of the
following strategies constitutes optimal diabetes management?
A. Discontinue glyburide and use metformin as a single agent.
B. Continue glyburide and add metformin.
C. Initiate insulin therapy.
D. Continue glyburide and add troglitazone.
E. Initiate acarbose as a single agent.
1. Bailey CJ, Turner RC. Metformin. N Engl J Med. 1996;334:574-578.
2. Steer ML, Waxman I, Freedman S. Chronic pancreatitis. N Engl J Med. 1995;
3. Watkins PB, Whitcomb RW. Hepatic dysfunction associated with troglitazone.
N Engl J Med. 1998;338:916-917.
4. Yee HS, Fong NT. A review of the safety and efficacy of acarbose in diabetes
mellitus. Pharmacotherapy. 1996;16:792-805.