Case study – part two

Mr White is a 67-year-old man diagnosed with IPMN (Intraductal Papillary Mucinous Neoplasm is lumps in the pancreas that are potentially pre-cancerous). 

• Weight: 71kg
• Height: 1.75m
• BMI: 23kg/m²

He previously had a steady weight of 75kg and a BMI of 24kg/m², equating to a 5% weight loss over 6 weeks.

Mr White was diagnosed with type 2 diabetes 5 months ago and referred to a diabetes management programme via his GP which involved group education sessions on diet, weight management and exercise. The diabetes was treated with diet and exercise to aim to reduce his HbA1c.

Mr White has always been active, walking 3 – 5 miles per day, swimming and line dancing 3 times per week. He has no family history of diabetes and has followed a balanced diet. Mr White was confused by his diabetes diagnosis and didn’t feel he had many changes to make. However, he has lost 4kg over the previous 6 weeks (which he thought was beneficial). Mr White has had a recent CT which showed a potentially resectable IPMN. The MDT plan was for him to have a total pancreatectomy.

Mr White’s appetite has been reduced for the last 2 months and his activity levels have been a bit lower.

He is currently managing to eat breakfast, lunch and an evening meal. He has been choosing lower fat options and eating more vegetables and salad based on the diabetes information he received.

His HbA1c is 68 mmol/mo

They consider the options of oral hypoglycemic agents (OHA: metformin or sulphonureas) or insulin to bring his BGs into the target range. They discuss the options with Mr White and agree that as he is planned for a total pancreatectomy, it would be beneficial for him to start on a basal insulin now as he will have to be on insulin after the operation. It will also help to optimise him for the operation as soon as possible.

They give him education on:

• checking his BGs with a glucometer,
• how to recognise and treat hypos,
• driving,
• injection sites,
• DKA,
• how to use and store the insulin pens.

He feels confident he can manage this at home. They give him written information and website links with the same information that he can refer back to it.

The diabetes team also explain to him what to expect with regards to his diabetes management after the operation.

• He will go onto a variable rate intravenous insulin infusion (VRIII) when he starts fasting for the operation (the night before). This will continue during the operation and initially afterwards.
• He will still have his injections of basal insulin.
• When he is eating or on an artificial feed, the inpatient team will plan to transition him from the VRIII onto insulin pens. The doses he will need will change as his intake and activity levels change after surgery.
• The first aim is to avoid hypos (BGs going below 4) during this recovery phase so initially his BGs are likely to be higher than they will aim for in the long term.

At this appointment he is started on a once-a-day injection of long acting insulin which he has in the morning. To start with he checks his BGs before each meal and before bed. He records these in a booklet so he can share them with the diabetes team when they phone him to review. They give him their contact details and tell him they plan to call the next week to see how he is doing and if he has any questions.