Case of the Month ESAP Special Edition: Diabetes and Aging

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Clinical Vignette

A 63-year-old man is referred for management of diabetes mellitus. His history is remarkable for adrenal insufficiency that occurred following bilateral adrenal hemorrhage after a logging accident 20 years ago. He takes prednisone and fludrocortisone daily. He also has hyperlipidemia and takes atorvastatin. Diabetes was diagnosed approximately 1 year ago, and metformin therapy was initiated at a dosage of 500 mg daily and slowly titrated to his current dosage of 850 mg twice daily. Initially this controlled his diabetes, but over the past 6 months, his hemoglobin A1c level has increased to 8.6% (4.0%-5.6%) (SI: 70 mmol/mol [20-38 mmol/mol]). Since his logging accident, he has had numbness in both legs and intermittent abdominal pain and cramping usually relieved by passage of gas. His abdominal episodes used to occur approximately once a month, but now he acknowledges symptoms at least once a week. He was told years ago to double his prednisone dose for 1 to 2 days whenever he was ill, and he admits to doubling his dose for his episodes of abdominal pain.

On physical examination, his height is 72 in (182.9 cm), and weight is 229 lb (104.1 kg) (BMI = 31.1 kg/m2). His blood pressure is 133/83 mm Hg, and pulse rate is 74 beats/min. He has diminished sensation on both legs distal to the knees, but his reflexes are normal and there is no skin breakdown. Findings on abdominal examination are unremarkable with normal bowel sounds, no guarding, no tenderness, and no masses or organomegaly. The rest of his examination findings are normal.


Which of the following is the best next step in this patient’s care?

  1. Re-educate the patient on appropriate sick-day rules for prednisone
  2. Add a sodium-glucose cotransporter 2 inhibitor
  3. Add a sulfonylurea
  4. Stop prednisone and start hydrocortisone
  5. Stop metformin and start a sulfonylurea


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