A 56-year-old woman with diabetes, hypertension, and hyperlipidemia is found to have an A1C of 11 despite her best attempts at diet and faithfully taking her metformin and glyburide. The patient mentions that she has been unable to exercise much, partially due to severe fatigue and sleepiness in the daytime. On examination she is obese, has a full appearing posterior pharynx, clear lungs, a normal heart examination, and trace bilateral edema. Reflexes and skin are normal. Her TSH is 2.0 m/L (normal). The patient asks if there is anything else that can be done before adding another oral agent or switching to insulin. What is the best next step?
Correct Answer: Arrange for a sleep study to check the patient for obstructive sleep apnea.
Description: Obstructive sleep apnea (OSA) that has gone untreated contributes to increased insulin resistance. This appears to have an additional effect even beyond the common cooccurrence of obesity as in this patient. Treatment of OSA can lead to improvement in glucose control. This patient is obese, has a crowded oropharynx on examination, and has daytime somnolence. Although overnight oxygen saturation monitor may be performed at home as screening, this patient is at high risk of complications of OSA should proceed directly to formal overnight polysomnography. Sleep hygiene is important for patients with sleep disturbance but is not likely to help in this patient with probable severe OSA. Similarly, sedative hypnotic agents such as zolpidem are widely prescribed for sleep but could exacerbate the OSA. Depression should always be explored but there are no clues beyond fatigue to suggest this diagnosis. Low vitamin D levels are generally asymptomatic unless the condition is severe and prolonged and would not affect sleep apnea or glucose control specifically.
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