Dr. Nanditha Arun: Screening for Obstructive Sleep Apnea in Patients with Type 2 Diabetes
CASE OVERVIEW:
A 69-year-old male with type 2 diabetes for 12 years presented to the out-patient department with complaints of unexplained lethargy and exhaustion for the past few months. The condition had gradually disrupted his activities of daily living. There were no other constitutional symptoms or history of weight loss or loss of appetite. His other co-morbidities were hypertension and dyslipidaemia, on treatment. The patient was on treatment with Sitagliptin with Metformin mg for management of his diabetes. His hypertensive therapy was on a triple drug combination; Cilnidipine, Carvedilol and Olmesartan, in maximum doses, despite which his blood pressure still remained high. The patient was also on a statin for dyslipidaemia. He is a non-smoker and a social drinker
DIAGNOSIS:
The patient was obese with a body mass index of 31kg/m2
Blood pressure – 160/100mmHg.
Other general and systemic examination revealed no significant findings.
On investigation, his reports revealed:
• HbA1c of 7.1%,
• fasting blood glucose -123mg/dl
• Post meal at 2 hr -189mg/dl
All other parameters including hemoglobin, lipids and renal function were normal.
Differential Diagnosis and Clinical discussion;
The clinical issues this patient had were in summary:
• Obesity
• T2DM – fairly controlled
• Systemic HTN – uncontrolled &
• Dyslipidemia….
• Unexplained lethargy and tiredness.
TREATMENT:
The possibility of hypoglycaemic events were low since the patient was on oral hypoglycaemic agents with low/ minimal risk of hypoglycemia, namely DPP-4 Inhibitors and Metformin. DPP -4 Inhibitors with a ‘glucose-dependent’ action and pose least risk of hypoglycemia to the patient. To further evaluate his glycaemic levels, he was subjected to continuous glucose monitoring, the results of which were satisfactory, with low glucose variability.
A cardiac evaluation including an echocardiography and ECG also showed no significant findings. A renal artery doppler was also done in view of uncontrolled hypertension, to rule out the possibility of renal artery stenosis despite optimal anti-hypertensive therapy. On further history taking, the patient’s attendant complained of his habitual snoring during sleep. This prompted further investigation for Obstructive Sleep Apnea (OSA) and a Polysomnography was requested to evaluate his sleep efficiency. The patient reported with moderate OSA with a score of >15. He was advised lifestyle modification and was put on continuous positive airway pressure (CPAP) therapy.
RESULTS:
On review after a few weeks, the patient reported with better health status and improved quality of life. Furthermore, the patient’s blood pressure also improved, with reduction in antihypertensive therapy. Empagliflozin 25 mg was added and the DPP-1V inhibitor was replaced with a GLP-1 analogue as well to aid further weight loss.
SUMMARY:
OSA is condition often overlooked in persons with obesity and metabolic disorders. It is essential for clinicians to suspect and screen for OSA in patients with long-term diabetes and metabolic syndrome, as if the condition remains undiagnosed and untreated, can result in detrimental effects in patient outcomes.
