Type 2 diabetes – using the art of bargaining and negotiation to achieve outcomes

7th October 2019. Dr Chee L Khoo

GPs are the experts in the practice of the art of medicine. There is a lot of subtle negotiation, bargaining and a touch of scare tactics that goes on when we consult with a patient with a chronic and complex disease. Patients with type 2 diabetes (T2D) comes as complex as you can get.

I first saw Rose 12 months ago. Rose is a Filipino enrolled nurse who does shift work at the local nursing home. She was diagnosed with T2D about 15 years ago. She was only a petite 64 year-old – a mere 48kg in a 1.5 metre frame giving her a BMI of only about 21 kg/m2. Diabetes was present across many generations – mother, uncles, sister and brother. She was pretty much doomed from the word go.

When I first saw Rose, she was on metformin, diamicron and Janumet. Her glycaemic control was said to be “good” according to her. Was that her interpretation of what her previous GP said or was she told that by her GP to prevent further conversation of what else to do? That happens. When we tracked down her last 5 HbA1c over the last couple of years, the so-called “good control” were more like HbA1c >10%.

A check of her retinas using my newfound toy, the retina camera revealed moderately severe non-proliferate retinopathy in one eye! Not surprising at all considering the level of her glycaemic control. She then admitted that the last time she saw an ophthalmologist some years ago, she was told that there was some diabetic damage to her eyes but no lipidil was ever prescribed. Her lipids were on target with simvastatin.

Her BP was bit high when first seen even for Caucasian standards. Her urinary albumin-creatinine-ratio (uACR) was 1.5. Her latest eGFR was >90. Her peripheral arteries, ankle brachial index and neurological function were all normal. So far, despite many years of poor glycaemic control, only one of her retinas is damaged. We need to get her glucose under control sooner or later.

Her self-monitored blood glucose (SMBG) revealed her fasting glucose were in the range of 9-10 mmol/L with post prandial readings in the range of 15-16 mmol/L with most meals. No wonder the HbA1c was so high. Interestingly, the bedtime readings were not much different from the morning readings suggesting that perhaps, there isn’t much beta cell reserves left. When you see a petite Asian lady who is generally sarcopaenic, chances are insulopaenia is more of a problem than insulin resistance. These issues become of prime importance when it comes to our treatment options.

Rose was only metformin, a DPP4 inhibitor and a sulphonylurea. What are our options here? I don’t have a magic pill. Could we add an SGLT2 inhibitor? Will it work? What about an GLP1-RA? Are we too late? Will Rose be agreeable to an injectable. Rose swear that she will never be on an injectable. After all her father died shortly after insulin was commenced years ago. She has seen many nursing home residents on insulin therapy who was getting lots of hypoglycaemic episodes.

Fast forward to the last blood test two months ago. Her HbA1c is still not on target at 8.8%. Better than 10-11%. How did we get there? I am sure that you see many patients like that in your practice. Do we throw our hands in the air and record in the medical notes that “I have advised the patient about insulin therapy but patient decline”. Just to protect ourselves. Or do we use our bargaining and negotiable powers to slowly, slowly coaxed the patient towards the target?

Come and share your stories about patients similar to Rose with your GP and allied health colleagues. Rose’s case will be one of the cases which will be workshopped at the DOMTRU Annual GP Diabetes Injectable Masterclass on Sunday 10, 2019 at Mercure Hotel, Liverpool. Let’s see what we can do for Rose.

The job is not done yet but we seem to be in the right direction. We’ve got Rose engaged in the management process.