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35-year-old patient with type 2 diabetes

History of present illness: A 35-year-old female with Type 2 diabetes presents for medication management. She was first diagnosed two years ago. She exercises regularly, has a BMI of 19 and has never been overweight. She has been taking metformin for twelve months. Despite taking her medication with food, this patient reports that she continues to experience gastrointestinal distress every day and is seeking advice or a solution. Her symptoms vacillate between nausea, severe constipation, and diarrhea. She's very interested in whether she can make any lifestyle changes to improve her condition; this patient wants to know if changing her diet further, adding in supplements, or making any other similar alterations could help her diabetes. She was told that her diabetes was not severe, and so she is hoping she can eventually get off her medication altogether.

Social history: Patient denies ilicit drug, tobacco, and alcohol use. She is single and lives with her cat. She works as a financial analyst for a local business.

Medication: Metformin.

Allergies: None.

Past medical history: Diabetes (diagnosed in 2018).

1. How would you suggest the patient's medication regimen be altered?

2. What lifestyle considerations (if any) would you bring up with this patient?

  • 3 weeks 3 days
    Would be helpful to know what her actual lab values were. Consider stool testing for pancreatic insufficiency. Considering her BMI of 19.... Would try her off Metformin and recheck lab values in 3 months. Consider exercise or walking after evening meal. Limit simple carbohydrates and processed foods. Consider change in foods... for 2 weeks.... any/all are potential options.... Begin with low FODMAP diet. Consider organic. Consider Gluten free. Nutrition referral likely very beneficial.
  • from Generation NP 1 month 3 weeks
    It is unusual for metformin to cause these sx after year. I would start with a I consult, stop the metformin, try an elimination diet. After the elimination diet trial, try a low processed foods diet, then introduce a DPP4. Get labs, including labs for celiac, sed rate
  • 1 month 4 weeks
    Work up for type 1 diabetes and check antibodies and peptide-c and family history . Switch to extended release metformin or to a different class like dpp4.. Dietary advise is important . Referral to dietician to be considered .
  • from Endocrinologist Nation 1 month 4 weeks
    A 33 year-old woman with a BMI of 19 is extremely unlikely to have type 2 diabetes. I agree with checking antibodies to rule out autoimmune diabetes (T1D/LADA), but that is also unlikely after two years on metformin alone. I would prioritize an evaluation for monogenic diabetes (MODY), which if due to glucokinase (GCK) mutations requires no treatment, or if due to HNF1A/HNF4A mutations would be better treated with a sulfonylurea. A family history is essential, and a HbA1c may be helpful to distinguish between GCK or HNF-MODY. Her "non-severe" diabetes suggests GCK.
  • 1 month 4 weeks
    Dependents on what her A1C level is at and if the A1C level is fine, I will switch her to extended release metformin 500 mg one pill a day with her largest meal and if this still bother her with GI symptoms, then I will discontinue Metformin and do diet control if her A1C level is good.
  • 1 month 4 weeks
    If the patient is otherwise doing fine, I would likely change her to a sustained release preparation of metformin.
    If symptoms persisted after the medication change, I think she would need further workup. It would be unusual to see a 35 year-old woman with Type II diabetes have a BMI of 19. Could she have celiac sprue, exocrine pancreatic insufficiency or another malabsorption or maldigestion syndrome? Could she be a Type I diabetic, under poor control with metformin and diet; she might have bacterial overgrowth or simply poorly controlled Type I diabetes.
    A complete history and physical, including all OTC and prescription meds would be indicated plus routine laboratory, including antibody tests for sprue, C-peptide and insulin levels and stool tests for volume and steatorrhea. Would defer GI consultation until these evaluations are accomplished.

  • from Generation NP 1 month 4 weeks
    I do not think she needs metformin at all. She is not likely to be insulin resistant. I suggest that the type of diabetes be re-examined. For lifestyle adjustments, I would suggest a daily walk after dinner. I would also review her carbohydrate intake, and suggest carbs that are slowly absorbed.. Has she been checked for Celiac disease?
  • from Generation NP 1 month 4 weeks
    I would like an extensive history and physical work up with family history and lab- including hgbA1C , anti-insulin and islet antibodies, and C- peptide . I would also have her keep a food diary and instruct on finger sticks three times a day for a few weeks and take a multivitamin with folic acid and b12 daily. I would ask her also to record her exercise and bowel habits. If she continues to have GI distress after changing to Metformin XL at night with food, I would refer to GI for possible scope. Celiac? Stress from job? Gastroparesis? I would also refer to Diabetic education- ? type 1 diabetic needs ruled out BMI 19 very low. She could also get nutrition support as well (decrease carbs, increase veggies BASED ON HER FOOD DIARY). She has been on the metformin for a year, that's a long time to suffer with GI distress- I appreciate the other members comments as I have had a few pts. like this who were misdiagnosed at the onset and are now doing great with insulin or other agents such as Amaryl . As providers we need to educate and monitor the long term effects of Diabetes as well. (Vision, feet, cardiovascular and renal). Medicine has change for the better for Diabetics and we need to continue to educate ourselves on treatments and medications to help them fight this chronic disease. I appreciate the comments listed .
  • 1 month 4 weeks
    I would switch her to time released metformin. This usually requires failed treatment with the short acting version and a prior authorization. I would check back in 1 month to assess for resolution of GI complaints. If improved, stay the course. If not, consider other med or supplement options and possible GI referral. Other considerations are education on a heart healthy diet (I generally recommend Mediterranean diet) and 30 minutes of exercise daily. I would recommend a daily multivitamin at minimum. I would also want to see A1c level, lipids, vitamin D, CBC, CMP. I find many of my diabetics are vitamin D deficient. Consider type I or type 1.5 DM in her case and order c petptide as well. IBS and Celiac disease considered.
  • from Pharmacist Society 1 month 4 weeks
    Metamucil nightly to see if GI symptoms resolve with a standard regimen to regulate GI symptoms in addition to moving to once daily Metformin XL and taking the Metformin with a meal. As for supplements, a good multivitamin would be preferred over individual vitamins in addition to weight control using diet and exercise. The patient's diabetes does not seem too bad, so this may allow her to come off the metformin after diet/exercise.
  • 1 month 4 weeks
    Patient needs to exercise; vitamin supplements to include Vitamin D; Cinnamon Bark and Chromium Piccolinate; Consider Dexcom Unit and reduce Metformin dose in half; using Glucophage XL.
  • from Generation NP 1 month 4 weeks
    I agree with many others that Metformin XR has potential to improve her A1c. I have had success with this myself. I think referral to GI could be considered to further workup her GI symptoms. Also I would closely look at the foods that she is consuming and closely examine her workout routines
  • 1 month 4 weeks
    Although she has only been a diabetic for two years, ?if she may have gastroparesis and needs a gastric emptying study. Also, she works at a stressful job and is single, her GI s/s may indicate IBS. Would like to know what her HgA1c is to see what is considered "not severe". May want to stop the metformin. May want to try a SGLT2 or DPP4 if sugars aren't bad due to low incidence of GI s/s. GLP may be another choice, but may get GI s/s from this and given the low BMI, would not benefit from possible additional weight loss. Would consider pro biotics and trial gluten free diet. Certainly consider turmeric/curcumin trial in her diet as well.
  • from Endocrinologist Nation 1 month 4 weeks
    1. Considering her young age at the time of diagnosis and low BMI, type 1 DM/LADA must be ruled out first. She could have T1D but is continuing to produce endogenous insulin at this time to obviate the need for intensive insulin therapy, but establishing the correct diagnosis will have implication on her treatment, as well as prevention of possible DKA in the future. Would test GAD65 antibody, IA-2 antibody, and zinc transporter 8 antibody. If antibody positive, this would be consistent with T1D/LADA. Would first stop metformin and if GI symptoms were to persist after stopping metformin, would then screen for celiac disease. If all 3 antibodies are negative, in addition to checking an A1c, would recommend for patient to perform SMBG 3 times a day or consider wearing a continuous CGM for 14 days to see her pattern of hyperglycemia. If hyperglycemia were to be mild and relatively similar throughout the day, may consider a DPP-4 inhibitor. If hyperglycemia were to be in association with a particular meal in the day, may consider a sulfonylurea targeting that meal.

    2. Would study the pattern of hyperglycemia as aforementioned, then refer to a dietitian to teach consistent-carb diet.
  • 1 month 4 weeks
    I agree with the endocrinologist in checking appropriate antibodies and the aforementioned tests. I also agree that patient may be converting to type ! due to Beta cell dysfunction. I would check the A1C, stop the metformin, and strongly consider insulin therapy if uncontrolled. I also would order celiac disease testing to see if gluten free diet would benefit this patient. I see no reason to use metformin at all and I would have her make appropriate diet supplements ie Glucerna to see if weight gain can be initiated.
  • 1 month 4 weeks
    I would need additional information - (1) A1c level , serum creatinine and GFR, c peptide , insulin auto abs , BG log ,
    (2) I would switch to diet only if A1c is good or try DDP4 or SGlt2 inhibitors.
    (3) also I would work up GI symptoms as her BMI is 19 and has symptoms to r.o IBD ,other GI conditions

    If due to metformin , then her symptoms should resolve soon after switching the med
    (4) also get Nutritionist consult to edu abt diet ,increase fiber etc
    (5) also another option would be to try met XR , but I have seen when given options pt would like to stop metfomin if they have been having GI issues.
    (6),also I would like to know if she has other comorbidities, h/o smoking ,alcohol , get medication list.
  • from Endocrinologist Nation 1 month 4 weeks
    I would probably not even consider trying XR - and just dc metformin, check a HBA1c . I would make sure that anti-islet cell abs (also GAD 65, ZnTransporter Abs) are negative. Her BMI is 19, and giving her SGLT2 inhibitors may cause her to lose some more weight, but given the other salutary effects of this class with regards to the heart and kidney, I would strongly consider it.
  • from Generation NP 1 month 4 weeks
    While early historical details are lacking in this case scenario, I have a perspective to share:
    A few years ago a pharmacist with BMI of 18, very healthy diet/lifestyle, and FBS 105-110 was referred to me by her PCP with Dx of pre-DM. Pt had a 3 mo trial of metformin which did not change her FBS levels, so the pharmacist/pt asked for an endo referral to me. Red flags went up right away. It turned out the pt had presymptomatic T1DM. I wrote the case up published in 2018. Here is the doi for anyone interested in reading further on presymptomatic T1DM: DOI: 10.1177/2165079917750169.
  • 1 month 4 weeks
    I need additional information about this patient, including her most recent hemoglobin A1C level and if she has had recent unintentional weight loss. I suspect, based on her BMI, she has evolving pancreatic endocrine failure(aka type 3C DM). I would recommend starting basal insulin, stop the metformin(due to GI intolerance), monitoring her weight and AM blood glucose levels, and adjusting therapy as necessary going forward. John
  • 1 month 4 weeks
    Yes I have never seen a diabetic with a BMI of 19; make sure her diagnosis is correct and stop the meformin or change to ER but she needs a work up on her GI symptoms. She also needs to increase her cARBS eat more VEGGIES AND WHOLE GRAINS.
  • from Pharmacist Society 1 month 4 weeks
    Try switching med to metformin ER take with food. Also refer to a dietician
  • 1 month 4 weeks
    Need to make sure she doesn’t have autoimmune diabetes. Check pancreatic auto-antibodies and c-peptide. Consider Metformin ER.
    Need to get additional information, including pre/post-prandial glucose levels, level and duration of her A1c measures. Nutrition referral. Consider ultrasound of pancreas and biliary tree. Evaluation for inflammatory bowel disease if symptoms persist.
  • 1 month 4 weeks
    Discontinue metformin and switch different meds along with diet and exercise
  • 1 month 4 weeks
    Either decrease dose or d/c metformin to avert GI distress; get HbA1C; if BP is elevated consider Jardiance or similar in category; check PPG - if this is only elevation, suggest Precose with meals....
  • from Generation NP 1 month 4 weeks
    First thing I always consider with a new pt is whether the dx is correct. Given the "mild" diabetes and thin body habitus, I'd want to see the first labs where she was dx. Could this be T1DM or MODY? T1DM antibodies can be checked along with fasting c-peptide/fasting glucose. If those are negative, can consider MODY genetic testing if the hyperglycemia is very mild,esp if just fasting < 110. If dx is truly T2DM and metformin ER is not tolerated even at a smaller dose, I'd move to DPP4 inhibitor as a next step.
  • from Pharmacist Society 1 month 4 weeks
    Check her A1C, check daily BS& her diet, make sure she is taking it with the largest meal of the day, switch to another agent if warranted after checking the first 2 items
  • 1 month 4 weeks
    Need to consider DM type 1, get the Insulin C-Peptide level and the Insulin Autoantibodies , consider metformin ER, to low gi side effects, after knowing A1c level ,If DM type 2 consider DPP-4 antagonist, if DM type 1 insulin .
  • 1 month 4 weeks
    GI distress is very common with metformin. She may be more comfortable with a GLP1 or an SGLT2. GLP1s are beta cell sparing and will be very effective for monotherapy control. Her A1c needs to be determined.
  • 1 month 4 weeks
    Very thin woman for type 2 diabetes; would screen for type 1 with c peptide levels, pancreas antibodies and consider other possible causes of gi distress besides the metformin; check alc level; metforminER may be better tolerated. Could she have a malabsorption issue given her low weight?
  • 1 month 4 weeks
    stop the metformin and try amaryl 4 mg bid
  • 1 month 4 weeks
    If continues to have symptoms then can try a different class of medications. Also I would see her back in 1 month. Also need to see her a1c before deciding on next agent too
  • 1 month 4 weeks
    Check for antibodies and then switch to extended release metformin
  • 1 month 4 weeks
    Need to distighuish if it is Type 1 Or Type Diabetes , Need to get the Insulin C-Peptide level and the Insulin Autoantibodies , If it is Type 2 Diabetes the can be given the trial of the Metformin Extended releease and see how she tolerates that if can not tolerate it then consider DDP-4 inhibitor if no contraindications , Ofcourse HbA1c will determine too the intensity of the diabetes management and the choice of the meds ! Consult with Nutritionist is in order and can use any of the diabetes management app for good bio feed back to control diabetes
  • 1 month 4 weeks
    I read the question and comments. Some advised she exercise regularly but the pt already exercised regularly. Some advised she lose weight but her BMI is already 19. I agree with considering altering her met Forman to an XR/DPP4 regimen. It would be important to know if the metformin was even effective by checking her A1c and home meter logs. Id also be interested to know what her diet consists of. Is it full of junk or does she need a diabetic dietician to review her carbohydrate and other dietary intakes. Ultimately more history is needed before altering her meds and/or lifestyle.
  • from Pharmacist Society 1 month 4 weeks
    could be changed to glipizide
  • from Pharmacist Society 1 month 4 weeks
    educate patient on her diet and foods to eat in moderation - carbs, food/drink high in sugar
  • from Pharmacist Society 1 month 4 weeks
    adding otc cinnamon capsule to help sugar levels
  • from Pharmacist Society 1 month 4 weeks
    consider adding regular exercise routine
  • from Pharmacist Society 1 month 4 weeks
    change to metformin ER
  • 1 month 4 weeks
    Sounds like a late-onset type I diabetic. Agree with C-peptide, and obviously we need to see HgbA1C. Should have been on ER Metformin long before now. If already on it, d/c it and if A1c> 7.0 consider low-dose glimeperide.
  • 1 month 4 weeks
    As an endocrinologist, family multiple versions that I want answered:
    1. What is her A1c and how long has it been it been in this range?
    2. Does she have a strong family hx of DM2?
    3. What are her fasting numbers, her time in range and her ore and post meal blood glucose levels
    4. How was she diagnosed with diabetes and does she have any underlying conditions that would make her hgb A1c unreliable?

    Since we don’t have those answers, I would first switch her to extended release metformin and would reassess her in 6-8 weeks. I would also have her bring her meter and a diary of her food intake to the visit. If she continues to have GI complications I would consider switching her to a DPP4 inhibitor since they are weight neutral. Her BMI of 19 is great and I would not want to give her anything to cause further weight loss. In fact it would make me question the etiology of her diabetes. She may be a MODY or a LADA. Having her family hx could help, but I may consider checking for antibodies or genetic testing for MODY. I would also question if her diabetes is under control as hyperglycemia can cause weight loss.
    Depending on what her diet log shows, I would have her reduce her carbs to 40-50 grams of carb per meal max. I could also set her up with a nutritionist and a code to teach her to carb count. I encourage the use of the MyFitnessPal app to help patients track intake and activity.
    As far as supplements, cinnamon, berberine, and inositol have some evidence of benefit in patient with diabetes. Given that the evidence is not as strong as it is for metformin for diabetes management, I would not prescribe any of these, but I would discuss them with her. I would maintain that if she decides to take any of supplements, she needs to monitor her blood sugars closely and come to see me at least 4 weeks post starting the supplements so we can make medication adjustments if needed.
  • from PA Unite 1 month 4 weeks
    I would consider extended release Met Forman or a Met Forman probably zone combination depending on the tolerance of the patient if this didn’t work I would consider a class change to possibly a SCLT2 or a GLP one inhibitor
  • 1 month 4 weeks
    First thing I would check in a thin, exercising over 30 yo are her pancreatic antibodies and C peptide to see if she may have LADA. Knowing a detailed family history may give some insight. If all her pancreatic antibodies are negative one might consider some branded extended release Metformins may be tolerated better and may be reasonable to try, my guess is that she will require another agent. I would likely opt for an SGLT 2 inhibitor, especially if she any evidence of microalbuminuria. Another option I would consider would be a DPP4 inhibitor at this stage.
  • 1 month 4 weeks
    Start low and go slow. Consider ER metformin. Take Metformin with meal and not empty stomach. Dietary supplements like prebiotics usually have no role in improving or decreasing GI symptoms due to Metformin. Since her BMI is only 19 rule out other possibilities for GI symptoms like Celiac.
  • 1 month 4 weeks
    I would work her up for type 1 diabetes for her normal BMI and her age. If she is type 2, consider ER metformin, also DPP4 if her HgA1c not at goal, and insulin if her baseline HgA1c is high. Review her dietary habits, what is her FBS and PPG, refer her to a CDE. What type of carb she takes?
  • 1 month 4 weeks
    A woman with a BMI of 19 and DM 2 is very unusual, especially one so young. A BMI of 19 is quite thin for a female and some would consider it underweight. I almost never see DM 2 in a person so thin. I recommend working her up for another cause, for example mild early type 1 DM, or pancreatic insufficiency due to a previous insult such as a bile duct blockage. It may well be DM2 and a GI side effect of metformin, but something in this case doesn’t fit to me. It would be nice to see her A1C, and a measurement of her insulin, C peptide, and anti insulin and islet antibodies. An ultrasound of the pancreas and biliary tree may also be helpful.
  • 1 month 4 weeks
    I would offer time released Metformin which freq resolves the GI sx or switch to a DP 4 inhibitor . I would increase bulk in diet and if continues to have diarrhea get a colonoscopy and a diabetic educator to review diet and behaviors. Must RO inflammatory bowel disease if perisists.
  • from Generation NP 1 month 4 weeks
    Sulfonylureas may be key to the solution.... although I feel changing to an extended release medication would be the right initial action, a drug class change may assist with the with s/s control, and in most cases can be taken in conjunction or alone for diabetic control. Complex carbs as a dietary supplement is integral along with routine daily exercise to include strength training in building muscle mass.
  • 1 month 4 weeks
    We could try the extended release Metformin XR and see if her symptoms improve. Her BMI of 19 is good. I would refer her to a dietician. Maybe adjust the type of carbohydrates she eats (whole grains vs refined sugars) and eat more vegetables for fiber.