Exhibit I: A Simpler Solution

From NESN.com

In my baseball playing days, I heard a Coach’s comment that stuck with me.  

And as with most aspects of Baseball, and sport in general, truth often transcends their original context.

"People that don’t know what they are doing can make something easy look difficult".  The converse is also true - those that have a higher level of skill can make something difficult look easy.

A parallel here, and certainly not a judgement on the management team of the patient being highlighted, is that it took a very challenging insulin pump regimen to keep this overweight Type 2 Diabetic in control.  In fact, to the Endocrinologist's credit, his regimen of both U-500 insulin in the pump, as well as 5 different daily basal settings, kept him well controlled with a decent Hemoglobin A1C.

Thankfully, after his Bariatric surgery, things got quite a bit easier.

Demographics:  47 y/o WM

Start Weight: 386   BMI: 49

Date of Surgery:  5/13  Gastric Bypass

DM2 History:  10 + years having a Diabetes diagnosis.  He was seeing Endo at the time of his entry H&P for management of his DM2.  Control was quite good with last glyco prior to surgery at 7.3, and management was with U-500 insulin in his insulin pump and 5 different basal settings throughout a 24 hour day. He was also taking Metformin 2G per day total.  No diabetic complications thus far.  He works as a truck driver and requires a waiver for his DOT  driver’s license with his Hx of DM and on Insulin. C Peptide on intake with us was 2.7.

Also with comorbidities of HTN, Hyperlipidemia, GERD, chronic LE edema,  OSA on CPap, and fatty liver changes.

Current DM Hx:  Last seen in June at his 3 month follow-up.  He was happy, doing well with no complaints.  His Pump regimen was able to be locked in at a basal rate of 0.25 U/Hr of his U-500 insulin, with his total daily dose of his insulin (in standard concentration dosing from greater than 120 units daily before surgery to now around 30 units per day), and his CHO: insulin regimen also similarly reduced for mealtimes.

He has had no substantial lows since his surgery, and is happier with his control and the more simplistic regimen that the surgery now affords him.

On his last visit at 3 mos post op, his weight is down to 279 now, BMI of 36.8, and he remains on his pravastatin and losartan, but is off Lasix, Metformin, and taking only 1/2 of his Atenolol dose as per previous.

Take Home Points:  Some of the interesting aspects of this case can be divided up into the perioperative Diabetic care, and then the longer term impact of the metabolic change after the surgery – which is still somewhat in evolution.

In the hospital, we took an “educated guess” approach to this patient’s post op insulin needs, taking into consideration his duration of DM, Glyco preop, insulin dosing, and his age.  I added up all of his total insulin for the day (basal + bolus/meal time dosing) which was then converted to U-100 dosing (multiplied by a factor of 5).  In this case he was well above 120 units per day of U-100 equivalent.  We then took roughly a quarter of the total daily dose and gave it to him in basal dosing (Levmir) and monitored his BGs QID. He did fairly well, averaging in the 120’s to 160’s perioperatively on that regimen.

Turns out that he was able to go home on that same dose of Levmir at 30 units per day which equillabrated to restaring his pump at 0.25 u / hr of U-500 insulin (therefore 6 units per day x 5 =30 units total of U-100 strength), until such time  he was to see his Endo for followup a few days post op.

He continues to see Endocrinology, and they are monitoring him to potentially further reduce his insulin needs as he continues to lose weight.  He is happy with his success thus far, and is fully aware that he likely will not completely get off insulin, but with its greatly reduced dose, and ease of administration (pumpless in the future with a fixed dose of Levmir and some metformin?)of his currently efficacious DM / insulin regimen, the future looks bright. 

He is ecstatic about his associated weight loss as well, already his improved quality of life, as well as the shedding of a number of his other meds, and is looking forward to his next visit in 3 mos with us in follow up.

Again, making the difficult look easy is usually the more difficult thing to do, but I am sure this patient is very grateful to live more 'simply' now vs. his life before he had his Bypass.