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‘My diabetes is out of whack’: Sometimes high finger-stick levels are easily cured
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A 58-year-old man followed for type 2 diabetes and hypogonadism called my office for an urgent appointment: His blood glucose levels had increased overnight from the low 100s to consistently being in the 200s, starting about a week before the call.
At the visit, the patient denied rhinorrhea, cough, sore throat, dysuria, fever, chills, sweats or lymphadenopathy. He claimed his diet had not changed and his new hyperglycemia was not responding to exercise at all. He had reasonably well-controlled type 2 diabetes with neuropathy for approximately 10 years.
He was tolerating his diabetes medications well and denied symptoms of hypoglycemia. He stated his libido had been good on testosterone supplementation, and erectile dysfunction was responding to tadalafil (Cialis, Lilly).
Ronald Tamler
Other medical history consisted of hypertension, hyperlipidemia, obesity, mild asthma that had not required steroids in a long time, diabetic neuropathy, arthritis, depression and a history of appendectomy. Family history was non-contributory. The patient did not smoke or use illicit drugs, rarely drank alcohol and was allergic to penicillin.
Medications included testosterone 1% (AndroGel, AbbVie) 3.75 g transdermal daily; atorvastatin 20 mg daily; liraglutide (Victoza, Novo Nordisk) 1.8 mg daily; metformin 1,000 mg twice a day; lisinopril 5 mg daily; tadalafil 10 mg to 20 mg as needed for intercourse; fluticasone propionate 50 mcg or 1 spray into each nostril daily; albuterol inhaler as needed; bupropion 75 mg twice a day; aspirin 81 mg daily; fish oil; vitamin C; vitamin E; and coenzyme Q10. He also took a nutritional supplement to help with neuropathic foot pain.
The patient weighed 214 lb (4 lb less than 3 months prior), and his vitals were as follows: blood pressure 130 mm Hg/85 mm Hg, heart rate 86, BMI 33. On physical exam, this was an obese well-appearing man, although his concern about his new high blood glucose readings was showing. Sensation to monofilament was intact in both feet.
He brought in his blood glucose meter, and the printout of the download showed the following fasting blood glucose (in mg/dL): 135, 142, 145, 208, 213, 209, 215, 204, 219, 220.
Chem12, complete blood count and microalbumin had always been normal; lipids and testosterone profile were at goal.
A point-of-care blood glucose in the office (at approximately 3 pm) yielded a blood glucose of 121 mg/dL. The incredulous patient demanded a repeat measurement, which was 127 mg/dL. Point-of-care HbA1c was 7.2%; it had been 7.1% at his previous visit 3 months prior. The patient was so thrilled that he gave me and my medical assistant a hug.
What is the next step in this patient’s management?
This image gives a clue as to the source of this patient’s misleading test results. Image courtesy of Ronald Tamler, MD, PhD, MBA.
A.) Have the patient take you out to dinner so you can observe his eating habits and form a closer bond.
B.) Provide reassurance and ask him to come back for his follow-up appointment in 3 to 6 months.
C.) Ask the patient to perform a blood glucose measurement with his own equipment in the office while you are watching.
D.) Stop testosterone supplementation.
E.) Explain to the patient that he probably has dawn phenomenon, which explains his high fasting blood glucose and normal afternoon values.
Answer: C
A sudden onset of increased blood glucose levels should always prompt suspicion for something that might be “cooking,” be it an infection, an autoimmune process or a change in medication. That’s why I overbooked this patient and spent a good amount of time quizzing him for any possible cause of hyperglycemia. Once the point-of-care data were back, the patient’s relief was palpable, and we were able to move on to other causes of his elevated finger sticks.
Direct observation of testing technique with the patient’s own supplies (C), even in “seasoned” patients with long-standing diabetes, can point to deficiencies in training or faulty equipment. In this case, the patient performed a textbook blood glucose measurement only minutes after our own glucose meter showed a level of 127 mg/dL, but his meter demonstrated a level of 247 mg/dL. Given his HbA1c of 7.2%, I felt confident that there must have been something wrong with the patient’s equipment. I took a closer look at his glucose meter and testing supplies, and his glucose strips were indeed 7 years out of date (see photo, page 37). Use of the strips coincided perfectly with the onset of high blood glucose measurements. The patient was “cured” with a fresh batch of strips.
While dinner with the patient would have been entirely enjoyable, it would probably not be representative of his eating habits and ethically questionable. A food log or, better yet, photographs taken with the patient’s smartphone of all ingested meals, drinks and snacks may provide better insight into his eating customs (A). Reassurance would have worked until the next day, leading (in the best case) to an alarmed phone call to the office, a switch to a different practice or, worst case, self-medication with glucose-lowering agents and hypoglycemia (B). Testosterone supplementation in hypogonadal men, in the setting of exercise, may lead to increased muscle mass and has been connected to improved insulin sensitivity in some studies, although I have not seen much of an effect on glycemia in my practice. Either way, a chronic medication should not suddenly affect blood glucose levels in such a manner (D). Dawn phenomenon (E) is something we see in our practice and would present with elevated fasting blood glucoses. This diagnosis might be supported by serial finger sticks throughout the day or continuous glucose monitoring. It also pays off to inquire about hypoglycemia, especially if HbA1c is normal, as was the case here. However, sudden onset elevation of fasting hyperglycemia from one day to the next makes this diagnosis unlikely.