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A 33-year-old woman with type 1 diabetes came to the clinic for help
adjusting her insulin pump therapy. She had been on the insulin pump since
shortly after her diagnosis was established 12 years earlier. She was a bright,
articulate, middle-level executive in a major company and knew more about pump
management than most of us, certainly more than me. She came to the clinic with
her husband and their 13-month-old daughter and she had very comfortably
managed her pump during pregnancy and the early hectic days of motherhood.
Earlier in the day she had seen her gastroenterologist, who had initiated
therapy with prednisone (Vintage Pharms) 20 mg daily and azathioprine (Azasan, AAIPharma LLC) for treatment of
autoimmune hepatitis. She has been forewarned of this regimen, which is why she
had made the appointment with me, but was appropriately concerned about
requiring frequent adjustments. She had been told that the azathioprine would
be only a short course but that she should anticipate requiring prednisone for
some time.
Together we designed changes to her insulin pump settings, made
arrangements for continuous glucose monitoring (CGM) for three days, and set
things in motion for her to purchase her own CGM.
When we had that all settled, she wanted to know how therapy for
hepatitis would affect the treatment of her thyroid disease. The physical exam
suggested she was euthyroid on her current replacement dose but I did order a
thyroid-stimulating hormone test to be sure since it which had not been
measured for several months.
When the result came back the next day the TSH was reported as 155 mU/L!
Autoimmune thyroid disease is a fairly common finding in type 1 diabetes
and usually easy to control but between baby, work and hepatitis she had paid
less attention to her thyroid medication more often than not missing a
dose. A repeat physical exam was unchanged, even knowing how hypothyroid she
was and I am still struggling to explain this other than a suboptimal exam by
me.
The prednisone is going to increase her insulin requirements and likely
have some positive effect on the hypothyroidism (albeit not standard therapy
for that). However, while she is recovering a euthyroid state her metabolic
rate will be in a state of flux and glycemic control will be hard to stabilize.
The good news is that she was stunned by the TSH, has a very supportive
husband and has taken a medical leave from work (working from home at her own
pace with great understanding from her company) to devote the time necessary to
care for herself and baby.
Three months into therapy for hepatitis she is off the azathioprine, her
TSH is normal and she has had no symptomatic hypoglycemic events. Her CGM data
are not so clean and it is an ongoing struggle to handle the diabetes, the
prednisone and the effects of prednisone on her weight and appearance.
Now it is time to think about the skeletal effects of steroid therapy,
so easily overlooked in someone with all that my patient has going on. With
type 1 diabetes she is likely to have lower bone mineral density when compared with her peers,
temporarily aggravated by pregnancy and lactation (bone loss during pregnancy
and lactation is not trivial but is almost completely recoverable under normal
circumstances). She does not really need to have a BMD test since it would not
influence my intervention decision, but the insurance would not cover her
therapy on the basis of history alone sometimes they refuse coverage
without a BMD even when the history includes an osteoporosis related minimal
trauma fracture. Of the several options available, I selected IV ibandronate
(Boniva, Roche) every three months, given as a short IV push since she is already scheduling
visits to one doctor or another that frequently.
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