Objective: Despite the availability of several new classes of antidiabetic medications, a large proportion of patients with diabetes mellitus fail to achieve optimal glycemic control. Adding glucagon-like peptide-1 receptor agonists (GLP1 RAs) to basal insulin regimens has shown to improve glycemic control in type 2 diabetes mellitus (T2DM). Methods: We present a patient with T2DM who had marked improvement in glycemic control accompanied by weight loss and a decrease in insulin requirement after adding weekly dulaglutide to U500 regular insulin. Results: A 56-year-old man with T2DM, class III obesity (weight 314 pounds, body mass index 46.4 kg/m 2), and hyperlipidemia had uncontrolled glycemia with a hemoglobin A1c (HbA1c) of 9.7% (83 mmol/mol) despite using high-dose insulin therapy and metformin. Physical examination was unremarkable except for obesity. His HbA1c remained high despite increments in insulin dosage up to 400 units per day. A few months after adding dulaglutide to his regimen, the patient's HbA1c declined to 6.3% (45 mmol/mol) despite significant reduction in daily insulin dosage to 20 units (94% decrease), which was accompanied by a 20-pound weight loss. Conclusion: The patient had a dramatic decrease in HbA1c, weight, and insulin requirement after treatment with dulaglutide. In the literature we could only find 1 study where a GLP1 RA (liraglutide) was successfully used in 15 patients receiving U500 insulin (average dose 197 ± 72 units/day). However, their reductions in weight and HbA1c were markedly less than observed in our patient. GLP1 RAs should be considered in patients with T2DM who require high-dose insulin therapy. (AACE Clinical Case Rep. 2019;5:e142-e145) Abbreviations: AWARD-9 = study of dulaglutide (LY2189265) in participants with type II diabetes; DM = diabetes mellitus; GLP1 RA = glucagon-like peptide-1 receptor agonist; HbA1c = hemoglobin A1c; T2DM = type 2 diabetes mellitus
Patient: Female, 58-year-old Final Diagnosis: Pancreatopleural fistula • pleural effusion Symptoms: Shortness of breath Medication:— Clinical Procedure: Thoracentesis Specialty: Gastroenterology and Hepatology • Pulmonology Objective: Rare disease Background: Pancreaticopleural fistula (PPF) is a rare complication of acute and chronic pancreatitis. PPF results from the release of pancreatic enzymes, either from a damaged pancreatic duct or pancreatic pseudocyst. This report is of a 58-year-old woman with a history of chronic pancreatitis associated with gallstones who had a known pancreatic pseudocyst that was being managed conservatively and who presented to the Emergency Department with pleural effusion due to a PPF. Case Report: A 58-year-old woman with past medical history of gallstone pancreatitis with subsequent development of pancreatic pseudocyst (being managed conservatively) presented with a 2-week history of progressive exertional shortness of breath. Physical examination indicated decreased breath sounds on the right lower lung fields. A chest X-ray revealed possible subphrenic free air. Laboratory test results were unremarkable except for elevated D-dimer levels. Computed tomography angiography revealed a large right-sided pleural effusion, which led to thoracentesis and the results illustrated elevated amylase levels. Magnetic resonance cholangiopancreatography was done, which showed pancreatic pseudocyst and possibly a fistula. Pancreatic enzymes were not checked in pleural fluid, as diagnosis was established with the presence of amylase and imaging findings. The patient felt better clinically after thoracentesis with volume removal and was discharged. She later underwent endoscopic ultrasound, which revealed a pancreatic duct leak requiring stent placement. Conclusions: Pleural effusions rarely occur secondary to PPF. Physicians must be wary of the presentation, especially in patients with a history of a conservatively managed pancreatitis pseudocyst. Early diagnosis and management can lead to prevention of long-term morbidity and mortality.
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