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The given study talks about Mr. GM, a 58-year-old male living in a Supported Residential Care facility with minimal support. He was presented after ten days of not eating and reporting symptoms like increasing weakness, polyuria and polyphagia. He also showed symptoms like diarrhea and vomiting and associated dehydration. He was treated initially with fluids and rapid-acting insulin. He was discharged on Lantus, Metformin and Gliclazide. Required referrals were made to the dietician, podiatrist and diabetes educator. He has a history of type 2 diabetes mellitus which was diagnosed in 2015, paranoid schizophrenia with episodes of listlessness, apathy and indifference, a chronic obstructive pulmonary disorder with an associated history of exacerbation and morbid obesity with a BMI of 45.1 kg/m2. His routine medications include- Sodium Valproate and Quetiapine. His HbA1c level was found to be 12% along with blood osmolality at 352 mOs/kg. His ketone level was 4.6 mmol/L and normal serial troponin levels. In this assessment, the diagnosis of the patient's condition, its management and pharmacokinetics will be discussed in detail.
Mr. GM presented with diarrhea, vomiting and associated dehydration after ten days of starving and associated symptoms like (frequent urination) polyuria, polydipsia (excessive thirst) and increasing weakness. He lives in a supported residential care facility with minimal support. His blood examination revealed an HbA1C level of 12% which is quite high and ketones level at 4.6mmol/L which is on the higher side as well (Khan et al., 2014). Type 1 diabetes antibodies tested and were found to be negative. Urine culture revealed the presence of a urinary tract infection as well. His pathology testing and symptoms together indicate the presence of diabetic ketoacidosis, a complication of diabetes mellitus (Burge et al., 2001). Two measurements of blood sugar testing in the past in 2014 also showed-high glucose readings like 6.3 and 6.4 mmol/L, but no follow up was done then.
The criteria for diabetes diagnosis include the presence of classical symptoms such as frequent urination, excessive thirst, polyphagia, associated weakness and unexplained weight loss among others (Khan at al., 2014). Presenting with any of the classical symptoms will lead to blood chemistry ordered by the physician for checking blood glucose levels to establish the presence/absence of the disease. A random blood glucose concentration of > 11.1 mmol/L, followed by confirmation with a follow up fasting blood glucose value of >7 mmol/L on a subsequent day or another occasion would confirm the presence (Levy, 2016). A glycosylated hemoglobin (HbA1C) value would also help in establishing the blood glucose control level of the patient in the past three months and is used in the diagnosis of his diabetes status. A value greater than 6.5% is indicative of poor control of blood sugar levels (Ali, 2020). An oral glucose tolerance test is also done in patients where diabetes/high blood sugar is not established via blood glucose or clinical symptoms. The blood glucose levels help to validate the presence of clinical symptoms and helps in confirming the diagnosis of diabetes (Tiwari & Kumar, 2018).
Diabetic ketoacidosis (DKA) involves a glucose concentration cutoff at 13·9 mmol/L (250 mg/dL) or higher to make the diagnosis of DKA, however, many patients have been observed with comparatively smaller increases in the glucose concentration in plasma after a decrease or absence of insulin dose due to illness or reduced intake of food (Dhatariya et al., 2017). In the case of Mr. GM, it is observed that the patient has a clear cut issue of raised blood sugar level along with high ketone levels and high HbA1c levels as well. His previous measurements of raised blood sugar levels in 2014 have not been followed up and adequate medication and diagnosis not given at the time.
Diabetes mainly manifests itself as a disturbance in glucose metabolism and homeostasis specifically manifested clinically as hyperglycemia. Type 2 diabetes is characterized by impairment of secretion of insulin, insulin resistance in adipocyte cells, muscle and liver, and abnormalities in the splanchnic uptake of glucose (Dhatariya et al., 2017). This leads to a condition of sustained hyperglycemia in the pathophysiology of type 2 diabetes mellitus. The factors leading to the same include decreased insulin secretion, increased lipolysis, and decreased effect of incretin, decreased uptake of glucose, increased glucose reabsorption and increased glucagon secretion (Zaccardi et al., 2016).
The defects occurring in the action of insulin, post its binding are the major cause of resistance of insulin in type 2 diabetes. Effects like decreased activity of insulin receptor- tyrosine kinase, abnormalities in signal transduction of insulin, reduction in the phosphorylation of glucose, impaired activity of glycogen synthase and decreased transport of glucose are seen as a result of the post-binding defects of insulin. Impaired synthesis of glycogen represents the main pathway that is responsible for the resistance of insulin in type 2 diabetes mellitus (Zaccardi et al., 2016).
According to Gosmanov, Gosmanova and Kitabchi (2018), diabetic ketoacidosis which is a medical emergency in the case of poorly managed diabetic mellitus can lead to symptoms like nausea, vomiting, diarrhea and abdominal pain. As in the case of Mr. GM, his ketones level is significantly high, it is clearly evident that due to lack of insulin in the body, the glucose gets accumulated in the blood which led to increased urination (Harvard Public Health, 2019). This eventually leads to the loss of various ions and water moles and salts out of the body and results in increased dehydration in the body and acidity of the blood. Stated that diarrhea is a common complication among patients with poorly managed diabetes due to various neuropathic changes (Selby, Reichenbach, Piech & Friedenberg, 2019). Also, the use of medications for diabetes control can lead to diarrhea among patients. Moreover increased urination with high glucose concentration is a favorable condition for the growth of microbial agents like bacteria due to which Mr. GM may have developed a urinary tract infection.
The primary aim in the case of management will include replenishment of the lost fluid to undo the ketoacidosis developed and also to reduce hyperglycemia through insulin administration. Fluid replenishment therapy helps in the restoration of this extra-cellular fluid volume and will help reverse the effects of dehydration (Gosmanov et al., 2014). This will lead to an increase in fluid in the plasma, thereby diluting the blood sugar levels or reducing them. This replenishment of fluid will lead to an increase in the blood supply in the periphery as well because of intracellular replenishment and an increase in the amount of electrolytes as well (Jayashree et al., 2019). This peripheral replenishment will help in decreasing the insulin resistance in the cells and it will also help in replacing the fluid loss occurring through urination. The intra and extra-vascular resuscitation decrease hyperglycemia by promoting osmotic diuresis. This causes enhancement of the peripheral action of insulin. It leads to a decrease in hyperglycemia and hyperosmolarity (Gosmanov et al., 2014). The administration of fluid also helps reduce the stimulus for the secretion of the counter-regulatory hormones as well (Jayashree et al., 2019). Therefore, it will help undo the dehydration effects and the presence of higher blood sugar. It will also undo the increasing insulin resistance in the body, thus the vicious cycle of insulin resistance and dehydration will stop. Fluid retention will continue until the blood chemistry shows normal levels of electrolytes in the body along with lower levels of blood glucose (Gosmanov et al., 2014).
The next step would be insulin infusion along with ketone and blood glucose level measurement. Insulin infusion will help in the treatment by promoting the utilization of blood glucose by the peripheral tissues which are required for the correction of metabolic acidosis. This would help reduce the blood sugar level in the body and prevent further worsening of hyperglycemia. It reduces glycogenolysis and gluconeogenesis and prevents ketogenesis as well. A decrease in the generation of new glucose and ketone and prevention of breakdown of glycogen will help decrease the blood sugar level in the body (Dunning et al., 2014). Regular monitoring of the blood glucose level can be done along with the initiation of insulin therapy through intravenous administration of insulin. Close monitoring by the nursing staff to maintain ideal blood glucose levels should be done along with urine output monitoring as well. Urine output monitoring will help in checking the levels of dehydration in the body. Blood glucose level monitoring will determine the amount and rate of insulin to be infused so as to prevent the patient from going into hypoglycemia (Corsino et al., 2017).
As Mr. GM is suffering from schizophrenia and paranoia, he is clearly unable to take care of himself or take proper medications on his own. He is also suffering from co-morbidities like morbid obesity with a BMI of 45 kg/.m2. He needs a referral to the dietician for proper diet control and management of weight along with a referral to a diabetes educator to educate him about his disease and how to control it. The dietician referral will help him lose some weight to prevent diseases arising from obesity to develop such as hyperlipidemia, hypertension, etc. The dietician will help make a proper diet chart as per his choices and preference for food (Stonajovska, 2017).
Since he is a mental health patient and suffering from multiple co-morbidities, a proper psychiatric referral will help in providing emotional support and psychological help. This will help in adherence to medication and also help with the management of weight, diet and diabetes condition along with the mental illness. Ensuring he gets his proper diet and meals daily is also extremely important to maintain fluid balance and prevent any such episodes in the future (RACGP Guidelines., 2015).
The patient is said to be on Quietapine and Sodium Valproate as a treatment for his mental condition. Quetiapine also shows its side effect in terms of causing increased hyperglycemia and new-onset diabetes mellitus (Rashid et al., 2009). Sodium valproate has been used previously as a treatment for neuropathic pain in type 2 diabetes mellitus. Also, clinical trials suggest that it could have anti-diabetic properties although the mechanism for the same is unknown (Rakitin 2017). As observed in Mr. GM, Quietapine causes moderate to heavyweight gain, both long and short term (Rashid et al., 2009). Also, Sodium Valproate is said to show its major side effects on the GI tract in terms of increased nausea, dehydration, vomiting and GI distress, some of which were observed in Mr. GM as well (Rakitin, 2017).
Diabetic ketoacidosis as observed in Mr. GM is also said to be a fatal complication of atypical antipsychotic use. Cases of DKA have been reported with the use of Quietapine in the past and its association with weight gain in the patient as well along with hyperglycemia (Das et al., 2018). It can be safely argued that the DKA associated with Mr. GM's case is associated with the use of antipsychotic drugs. Interestingly, in schizophrenia, DKA is often the first sign of antipsychotic (AP) drug-associated diabetes mellitus among patients (Vuk et al., 2017).
The management did not involve proper emphasis on diet control and how his psychiatric condition and living condition is affecting his obesity, blood glucose levels and current status. Nursing intervention is required in the form of patient education for proper blood glucose monitoring by the patient through the teach-back method (Judge, 2020). Also, proper counseling with regards to the effects of his antipsychotic medications including complications like insulin resistance and hyperglycemia needs to be done along with regular screening for insulin resistance. This will help the clinicians to individualize treatment decisions and reduce any iatrogenic contribution to the onset of diabetes (Vuk et al., 2017). The medications like Metformin and Gliclazide should be given with a proper prescription of the doctor. They work best with proper diet modifications and weight management (Song, 2016). Also, Lantus insulin was also prescribed to him for diabetic management. Metformin is the first line of treatment for type 2 diabetes mellitus, whereas Gliclazide is a sulfonylurea. Both are usually not prescribed together. Metformin is responsible for some weight loss in obese diabetic patients whereas, Gliclazide shows its effect more on glycemic control than weight loss (McAlpine et al., 1988).
Bariatric treatment with regards to his moderate obesity can also be suggested and followed up. Treatment in the form of gastric bypass, sleeve gastrectomy surgery and gastric band surgery can also be suggested for him to lose the weight and reduce his chances of developing co-morbidities like hyperlipidemia (Wolfe et al., 2016).
The case study of Mr. GM as discussed here helps in establishing the criteria for diagnosis and management of type 2 diabetes mellitus. The patient suffered from an episode of diabetic ketoacidosis – associated dehydration, infection, vomiting and diarrhea and was brought in to the hospital for the same. There was a lapse in his previous management of high blood glucose levels previously tested in 2014 and no proper medication was provided then. Since the patient is a psychiatric patient as well, he needs a proper psychiatric and counselor referral to provide emotional support and help him in his adherence to medications. Bariatric options should be discussed with him for his weight and proper counseling and meal planning by the dietician as well. The adequate arrangement needs to be made concerning his meals, diet and living conditions as well. After this episode, a diagnosis of type 2 diabetes mellitus was made and he was discharged on Metformin, Gliclazide and Lantus insulin to help control and maintain his symptoms and high blood sugar. Along with this, a referral to a dietician, diabetes educator and liaison with SRF was also done. This case helped understand the effective and proper management of diabetes.
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