56 Year old male with Type 2 Diabeties Mellitus with History of Carcinoma Bladder
CHIEF COMPLAINTS
This is the case of a 56-Year-old male, a shopkeeper by occupation who presented to the hospital with complaints of
- Lower back pain for 5 years
- Chest pain for 2 years
History Of Presenting Illness
The patient was apparently asymptomatic 23 years ago.
23 years ago, the patient experienced polydipsia, polyuria and polyphagia and visited a doctor. On further investigations, the patient had 400 mg/dl fasting blood sugar and was diagnosed with Type 2 Diabetes Mellitus. The patient was started on antidiabetic medication.
The patient currently has a tingling sensation and blurred vision at times.
10 years ago, the patient had one episode of hematuria. The patient visited a hospital. After evaluation, the patient was diagnosed with High-Grade Urothelial Bladder Carcinoma, without any muscular involvement.
The patient underwent surgery for the same and was advised a follow-up every 2 years since.
7 years ago, the patient was diagnosed with Hypertension and was given Olmesartan Medoxomil 40 mg
5 years ago, the patient slipped and fell on his right side, on a cement road, from a terrace 8 feet above the ground.
The patient was disoriented for 2-3 minutes after falling. Since the fall the patient experienced lower back pain which was dull in character, experienced on and off, and radiating to the front. The pain is aggravated on sitting continuously in one position and relieved on changing position or stretching.
Since 2 years, the patient is experiencing Chest pain localised to the right and left side of the sternum, which is dull in character, lasting 5- 10 minutes. The patient experiences 2-4 such episodes per month. The pain aggravates on exertion and is not associated with Nausea or Vomiting.
PAST HISTORY
The patient is not a known case of TB, CVD or Epilepsy
No history of allergies
TREATMENT HISTORY
Treatment for Bladder Carcinoma -
The growth was 1.3 cm, pedunculated, in the posterior wall of the urinary bladder.
- Surgical treatment: Total excision of growth with underlying detrusor excision
- Medical management :
- Intravesical BCG instillation 6 cycles were started 6 to 8 weeks after surgery
The patient is currently taking
- Metformin Hydrochloride (Prolonged release ) and Glimepiride Tablets
- Vildagliptin and metformin hydrochloride tablets (50 mg + 500 mg)
- Olmesartan Medoxomil tablets 40 mg from the past 7 years - once every two days
PERSONAL HISTORY
Appetite: Normal
Diet: mixed diet
Sleep: Adequate
Bowel and bladder movements normal
No history of allergy
Addictions: The patient is a chronic smoker (the patient does not recollect when he first started smoking ), and currently consumes 2-4 cigarettes a day
No history of alcohol consumption
FAMILY HISTORY
The patient's grandfather had a history of Diabetes Mellitus type 2
No Family history of cancer
GENERAL EXAMINATION
The patient is conscious, coherent, and oriented to time place and person.
The patient is well built and well nourished
Pallor - Absent
Icterus - absent
Cyanosis - Absent
Clubbing - Absent
Koilonychia - Absent 
Lymphadenopathy - absent
Oedema - Absent 
VITALS
Temperature - afebrile
Blood Pressure - 110/70 mmhg
Pulse rate - 87 beats per minute
Cardiovascular Examination
S1, S2 Heard
No thrills and Murmurs
Respiratory Examination
BAE +
NVBS heard
CNS Examination
The patient is conscious coherent and oriented to time place and person
No Focal Neurological Deficits
INVESTIGATIONS
1. Ultrasound Report
3. X-RAY Abdomen AP View
4. Cystoscopy
No Recurrence, No growth
BIOCHEMICAL INVESTIGATIONS
Opthalmology Cross Consultation notes
Provisional Diagnosis
- Type 2 Diabetes Mellitus with a history of carcinoma of the urinary bladder
- ? spondyloarthropathy
Treatment
Tablet Gemer 2mg PO/BD
Tablet Vylda-M 50/500 PO
Case discussion
Thanks.
Share your questions around this patient
:
Yes sir
1. Was trauma the only cause of the lower back pain ?
2. What was the role that DM played in the generation of carcinoma of the bladder ?
We had a hunch it was one of his early medication before 2013 that was subsequently banned for carcinogenicity particularly urinary bladder. Can you find out which medicine it was? Also please tell us what treatment he received for his urinary bladder carcinoma
Pioglitazone sir
The cohort generated 689 616 person years of follow-up, during which 622 patients were newly diagnosed as having bladder cancer (crude incidence 90.2 per 100 000 person years). Compared with other antidiabetic drugs, pioglitazone was associated with an increased risk of bladder cancer (121.0 v 88.9 per 100 000 person years; hazard ratio 1.63, 95% confidence interval 1.22 to 2.19).
Also expected outcomes? Chances of recurrence?
: Sir , the patient was given
6 cycles of intravesical bcg.
: What is the usual standard of care in such situations? What was his stage and tumor grade at the time the treatment plan was made?
Transurethral resection of the bladder tumor allows for definitive diagnosis, staging, and primary treatment. Non-muscle-invasive disease is treated with transurethral resection, most often followed by intravesical bacille Calmette-Guérin or intravesical chemotherapy
: Sir our patient had high grade superficial urothelial carcinoma without any muscle involvement thus the treatment given was tumor excision with intravesical BCG instillation
: What are the past reported outcomes (clinical epidemiologic data) in terms of recurrence with this approach?
: Also what is the rationale for adding a gliptin to his sulphonylurea secretagogue?
Patient / Problem: The aim of present study is to compare the efficacy and safety of adding vildagliptin with sulfonylurea dose-increasing as an active comparator in patients who had inadequately controlled type 2 diabetes mellitus (T2DM) using metformin plus sulfonylurea in real clinical practice
The mean HbA(1c) at baseline was 8.6% (70 mmol/mol) in both groups
Intervention :
Patients using metformin plus sulfonylurea were assigned to either vildagliptin add-on (50 mg twice a day, n=172)
or
sulfonylurea dose-increasing by 50% (n=172) treatment groups.
Comparator
The primary endpoint was a change in HbA(1c) after 24 weeks.
The secondary endpoints were patients achieving HbA(1c)≤7.0% (53 mmol/mol)
-changes in the fasting plasma glucose (FPG)
- 2-h postprandial glucose (2pp), lipid profiles, and urine albumin-to-creatinine ratio.
-Body weight and hypoglycemia were also investigated
Outcomes
-At week 24, the adjusted mean HbA(1c) levels decreased by -1.19% (-13.09 mmol/mol) with vildagliptin add-on
and -0.46% (-5.06 mmol/mol) with sulfonylurea (P<0.001).
-Significantly more vildagliptin add-on patients achieved HbA(1c)≤7.0% (53 mmol/mol) than did sulfonylurea patients (40.1% vs. 7.9%; P<0.001).
-Greater reductions in FPG and 2pp were observed with vildagliptin add-on than with sulfonylurea (P<0.001).
-The vildagliptin add-on group exhibited no clinically relevant weight gain and had a
lower incidence of hypoglycemia compared with the sulfonylurea group
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