Patient case highlights need for screening in diabetes

I have been watching the buzz about screening for prediabetes with mixed feelings. The earlier in the disease one can make the diagnosis and start the patient on the correct path to optimal control the better. My issue is that I see far too many patients referred who have either received no education about their disease or its management or the information hasn’t sunk in.

When a patient reports that home glucose monitoring has not been discussed and they go to their doctor every three or four months for the “AC test or whatever it’s called,” I shudder that they might be giving me correct information.

On the flip side, patients must be involved in their own care. By all means screen for prediabetes and most definitely make a diagnosis when the recognized criteria are met, but don’t forget the importance of patient education about diet and lifestyle modification. Therapy for diabetes should start with lifestyle modification.

One of my patients made a case for screening this week when she demonstrated that diabetes can be asymptomatic even when glucose levels are sky high. D, an 80-year-old wheelchair-bound delightful woman on long-term prednisone recently doubled her steroid dose and I in turn increased her glargine by 25%. I had her call me every day with her fasting and bedtime glucose and increased her glargine on a daily basis for a week as her values kept rising. At 450 mg/dL, it was time to come in and be evaluated.

She hadn’t felt this well for a long time despite her high glucose. The steroids were obviously doing their thing. I could get no symptoms of marked hyperglycemia whatsoever. My initial thought was that her blood glucose meter was wrong, but I was puzzled that she had not had any hypoglycemic symptoms either. I sent her down to the emergency department without hesitation, first warning them that it might simply be a non-working meter issue as has happened to me before. If the blood glucose was OK she could go home. If the meter was OK she needed to stay.

The lab glucose value was 507 mg/dL and intensive insulin therapy was started.

I wonder just how many patients there are out there with a blood glucose >500 mg/dL and feeling perfectly well. Fasting blood glucose should be an integral part of the annual check-up, but it seems that fewer folks have an annual physical. How far beyond that should we go in seeking out this disease?