There are days when you wish you could have made a difference and there are days when you know you did.
I had a patient yesterday morning who was not new to diabetes but new to me. She had been diabetic for a few years taking a single pill for her disease. She wasn’t doing well and her endocrinologist started her on insulin and rapidly increased her over the last year. This is not in and of itself a strange story. What is odd however is that he chose to put her on an insulin pump, an expensive device usually reserved for type 1 diabetics. By this time, she was up to 200+ units of insulin a day and had gained 40 pounds in the last year as a result. A common story in my office, she already had an endocrinologist but wanted a second opinion about her care. What really caught my attention was that she also said that ever since starting insulin she had begun experiencing seizures. She had no previous history of seizures and the neurologist could find no reason for them either. Regardless, she was started on anti-seizure medication and her endocrinologist just continued to increase her insulin dosing despite worsening seizures.
If you aren’t scared for this patient yet, you should be. Here we have a 50-ish year old women gaining 40 pounds a year from a medication that if it has not actually induced a new seizure disorder, the coincidence shouldn’t be ignored. Hypoglycemic seizures is the first thing every endocrinologist should think when they hear this kind of story. The patient has blood sugars in the 250-350 range (normal = 70-140) ALL THE TIME and yet she is taking more than 10 times the typical daily human insulin needs (usually 30-50 per day), which means that she is very insulin resistant as well. Why none of this had been addressed really irked me. Let me also make something very clear, this patient is a very reliable historian – so believable; I also know that for many endocrinologists this is not atypical prescribing behavior.
I immediately had her discontinue her insulin pump, I mean I had her pull it off right then and there. I gave her a prescription for an insulin sensitizer, a GLP1-RA, a SGLTi all at once. About noon, I gave her first injection of the GLP1 agent and her first pill of the SGLTi while she was sitting there. This sort of aggressive combination therapy for diabetes has been codified in the American College of Endocrinology guidelines for years by many well validated studies. Most importantly, NONE of these medications can cause hypoglycemia either alone or in combination.
Around 6 pm she called me to tell me her blood sugar was 136. Normal. I could hear the emotion in her voice as she told me she hadn’t seen a normal blood sugar in so long she had forgotten what it felt like. I hooted and hollered and was so happy for her that I got tears in MY eyes.
These phone calls. Those blood sugars. This patient. That is why I’m here.
Dr Christofides