Exhibit H: An Adventure with C Peptide - The Word is Out

Photo by Wonderlane

The word is out.

Patients are starting to come to the office more frequently and ask the informed questions:

"What are the chances I will be able to get off my Diabetes medicines after surgery?"  and

"What procedure is best for me with my Diabetes?"

This is a great place for the fasting C Peptide test.  I haven't seen anyone yet come in as a new patient with a recent C Peptide result, but it can be a great starting point for the discussion about having another point on the curve to more accurately predict metabolic response to surgery (Bypass, Sleeve) in terms of Diabetes improvement / regression / remission. As mentioned earlier, other studied and non-studied points on that curve seem to be:    

     *Duration in Years for DM2?
     *Insulin use Currently?
     *Hgb A1C at Time of Presentation for Surgical Consult? / Degree of Current DM Control
     *Age of the Patient?
     *BMI?

I still suspect that the C-Peptide result trumps other indicators, as it directly reflects current endogenous insulin secretion, which is essentially the net effect of the above factors. It summarily mirrors the 'up to the minute' status of pancreatic B-cell function, which is what are looking to preserve, and capitalize on, with surgery and its attendant metabolic advantages, and additional weight loss.
 (See previous Blog post on the Number 3)

Today's Case...

Demographic  54 y/o WF

Start Weight  248  BMI 48

Date of Surgery  1/16/13  Gastric Bypass

DM2 Hx:  At the time she was referred to us for evaluation for weight loss surgery, she was on Levemir 60 u daily, Humalog scale generally 50 u BID, and Glimepiride 4 mg daily.  Her control around the time of our evaluation was deteriorating, as reflected in her most recent Glyco of 10.7.  Associated comorbidities were poorly controlled HTN, Hyperlipidemia, and Chronic Fatigue, and a questionable Hx of an ICU admission in the recent past for acute renal failure brought on by an illness with dehydration, but she did bounce back and did not require dialysis or any long term additional treament.

Current DM Hx:  Perioperatively, she was placed on scale and required light dosing of Novolog for BGs in the range of 150-170s.  No basal was ordered, as we waited to see how she would settle out after her Bypass.  

We were also armed with a C-Peptide of 2.3, which was indicating her pancreatic reserve was limited, and I suspected she would need some insulin, either Basal and/or short acting as her diet picked up post D/C.

At last check, after her 1 week visit, and since (I spoke with her just this past week) she is off all insulin and takes no PO antidiabetic meds, and her BGs are in the 100-120 range with her advancing diet.

Take Home Point:


As the title of this Blog post indicated, our patient came into the office very concerned, and asking those 2 big questions. They were of such importance to her, that if we couldn't have given her at least a qualified response, she was leaning hard toward not having surgery.  She wanted some kind of guarantee that her DM would at least be substantially improved, but hopefully put into remission or regression.  

Her other medical issues, her quality of life with her obesity, and her awareness of her likely shortened lifespan from her aggregate medical status was not enough to initially convince her of the need for surgery.

At her first visit to the office, we did discuss obtaining the C-Peptide test, which did turn out to be well below the 3.0 threshold that usually correlates with substantial and rapid DM improvement after surgery according to the literature.  I reviewed the importance of the blood test in her situation, and once we had the result,  gave her the news about the reduced likelihood that we would likely not "hit a Homerun" with surgery, and she would most likely not walk out of the hospital as a new member of the sugar-free gang.  

Looking back, though, as part of the initial discussion I had with her I did go into detail about her current health status, and where she was headed should she not experience any reasonable weight loss in the near future.  This is also an important part of the full disclosure of her options as well, I feel.   

Obviously, Surgery has risks, but "doing nothing"(as far as making a significant difference in sustained diabetic control through medicines, lifestyle, and weight loss) certainly has real risk as well.  

And, as far as DM2 goes, 'Time is Pancreas'. 

There is a finite amount of insulin those B-cells can produce, and when it's done, it's done.

So, currently for this patient, she is definitely better for the time being, and we will have to see how she does long term, as indicated by her C-Peptide. Even if her DM does recur in subsequent years, it will be much easier to control for the long term.