End of the Road: Diabetes Care When Insulin May Not Be an Option.

PRESENTATION J.U. is a 53-year-old man with uncomplicated type 2 diabetes who requires a commercial driver’s license (CDL) for his occupation as a truck driver and mechanic. His diabetes was controlled with increasing doses of metformin and glipizide during the first 4 years after his diagnosis. Despite nutrition counseling, diabetes education classes, and physician visits every 3–6 months, nonadherence with therapeutic lifestyle changes contributed to his A1C fluctuating between 7.2 and 10.2% over 3 years. His health care provider recommended insulin therapy numerous times, but J.U.’s needle fear, lifestyle preferences, and fear of losing his job led to patient refusal and clinical inertia. He is seen for an urgent appointment after his Department of Transportation (DOT) physical was failed for hyperglycemia (glucose > 200 mg/dl) and significant levels of glucose in the urine. He reports fatigue, polyphagia, polydipsia, and polyuria. He has not been compliant with self-monitoring of blood glucose (SMBG) or recommended therapeutic lifestyle changes. At the time of this visit, his diabetes medication regimen consists of metformin 1,000 mg twice daily and glipizide 10 mg twice daily with meals. His A1C is 8.1%, weight is 207 lb (BMI 32.5 kg/m), blood pressure is 110/72 mmHg, pulse is 80 bpm, serum creatinine is 0.9 mg/dl, total cholesterol is 116 mg/dl, triglyceride level is 207 mg/dl, LDL cholesterol is 46 mg/dl, and HDL cholesterol is 29 mg/dl. He has a known history of hyperlipidemia treated with a statin, hypertension treated with an ACE inhibitor, and gastroesophageal reflux disease treated with a proton pump inhibitor. He has smoked two packs of cigarettes per day for 32 years, with multiple failed quit attempts, and denies alcohol or illicit drug use. J.U. provides the primary source of income for his family and has financial difficulties. Having to stop work, even for a brief period, would be financially devastating to his family. His physician signs a medical examination form certifying that his diabetes will be closely monitored and managed, which will allow the patient 6 months to control his diabetes and pass the DOT physical. The patient is referred to the clinical pharmacist to provide diabetes disease state management as part of a collaborative practice agreement within a patient-centered medical home.