Diabetes Mellitus, Type 2

Clinical Summary

Type 2 diabetes mellitus diagnosed based on HbA1c of 6.7% in July 2025. No diabetes-specific medications documented in available raw sources.

HbA1c appeared to improve from 6.8% → 5.7% (Nov 2025 → Mar 2026), falling into pre-diabetic range. However, fructosamine testing on Apr 22, 2026 revealed elevated level of 310 µmol/L (reference 122–236), indicating poor short-term glucose control. This HbA1c-fructosamine discordance strongly suggests the HbA1c improvement is spurious, likely due to altered red cell turnover from AML treatment (azacitidine/venetoclax). True diabetes likely persists.

HbA1c Longitudinal Tracking

Trend Analysis

HbA1c appeared to decrease from 6.8% to 5.7% between November 2025 and March 2026, moving from the diabetic range into the pre-diabetic range. However, fructosamine testing contradicts this apparent improvement.

Fructosamine 310 µmol/L (HIGH) on Apr 22, 2026 despite HbA1c 5.7% (pre-DM) on Mar 2, 2026.

Fructosamine reflects 1–2 weeks of glycemic control and is not affected by red cell turnover, hemolysis, or transfusions. The elevated fructosamine indicates true hyperglycemia despite the "improved" HbA1c.

Interpretation: The HbA1c improvement (6.8% → 5.7%) is likely spurious, caused by:
- Increased red cell turnover from azacitidine/venetoclax
- Shorter RBC lifespan in AML
- Transfusion dilution (if transfusions given)

Conclusion: Diabetes is likely still active and poorly controlled. Fructosamine should be used as the primary glycemic marker going forward, not HbA1c. Consider home glucose monitoring and diabetes-specific medication.

Glycemic Monitoring — Recommended Markers

Historical Diabetes Regimen (November 2022)

[!info] 2022 Medication List — Pre-AML Baseline
From raw/clinic-notes/2026-05-06_note.md (November 25, 2022 medication list):

Medication	Dose/Frequency	Route	Notes
Insulin Degludec (Tresiba)	10 units, once daily morning	SC	Same as 2026
Linagliptin (Trajenta)	5 mg, once daily morning	PO	Same as 2026
Metformin XL (Glycomet XL)	500 mg BID (morning & night)	PO	Extended-release, 1000 mg/day — dose escalated to 1500 mg/day by 2026

Absent in 2022 vs present in 2026:
- Insulin Glargine (Glin) — NOT in 2022, added later; appeared on 2026-05-04 Rx but patient confirmed NOT taking it (clinic note 2026-05-06). Prescribed but non-adherent.
- Pregabalin — NOT in 2022, added later (neuropathy developed post-2022)

Also on 2022 Rx (non-DM context):
- Simvastatin 10 mg bedtime → replaced by Atorvastatin by 2026
- Cholecalciferol 2000 IU (continuous from 2022 → 2026, same dose)
- Menorease (discontinued by 2026)
- Pregmerve (multivitamin/folate — discontinued, likely replaced by Renerve)
- Vitamin E Evitol 400 mg (discontinued by 2026)

[!info] DM Diagnosis Pre-dates 2022
The presence of insulin + DPP-4 + metformin in November 2022 confirms diabetes was already established and on multi-drug therapy well before the HbA1c of 6.7% documented in July 2025. The date_onset: 2025-07-01 in this record reflects first documented HbA1c, not actual diagnosis date. True onset predates 2022.

Medications (Newly Documented 2026-05-04)

A handwritten prescription dated 2026-05-04 revealed 4 diabetes medications that were NEVER previously documented in any ingested raw source (no prescription PDFs, no clinic notes mentioning diabetes treatment).

Date of initiation unknown for all medications.

Current Diabetes Regimen

1. Insulin Degludec (Tresiba) — 10 units subcutaneous once daily
2. Ultra-long-acting basal insulin analog

3. Provides 42+ hour coverage

4. Linagliptin (Tradjenta) — 5 mg oral once daily (morning, 1-0-0)

5. DPP-4 inhibitor (gliptin)
6. Glucose-dependent insulin secretion
7. No renal/hepatic dose adjustment required (ideal for AML setting)

8. No CYP3A4 interaction with posaconazole

9. Metformin (Glulucamio) — 500 mg oral three times daily (1-1-1, total 1500 mg/day)

10. Biguanide antihyperglycemic
11. First-line agent for type 2 diabetes
12. Monitor renal function (renally excreted; contraindicated if eGFR <30)
13. Current renal status: creatinine 0.7–0.9 mg/dL (normal)

Additional Medication Affecting Glucose

[!info] Prednisolone — NOT BEING TAKEN (Confirmed 2026-05-06)
Clinic note 2026-05-06 confirms patient is not taking prednisolone (Predniod). Steroid-induced hyperglycemia risk from this agent is therefore no longer active. See Prednisolone.

Glycemic Control Assessment

Despite this multi-drug regimen (1 basal insulin + DPP-4 inhibitor + metformin), glucose control remains poor (last measured):
- Fructosamine 310 µmol/L (Apr 22, 2026) — HIGH (reference 122–236)
- Indicates inadequate glycemic control over prior 1–2 weeks

[!success] Dual Basal Insulin — RESOLVED (2026-05-06)
Patient confirmed NOT taking insulin glargine (Glin). Active basal insulin = Tresiba (degludec) 10 units only. The apparent dual-insulin regimen from the 2026-05-04 prescription was due to non-adherence.

[!info] Adherence Pattern (May 2026)
Three of the 11 medications on the 2026-05-04 prescription are confirmed NOT being taken: nifedipine, atorvastatin, and insulin glargine (Glin). Actual adherence to remaining medications is unconfirmed.

Possible explanations for poor glycemic control:
1. Suboptimal insulin dosing (10 units degludec may be insufficient)
2. Poor medication adherence (13 total active medications — polypharmacy)
3. Lack of home glucose monitoring (no documented fingerstick glucose readings)

No home glucose monitoring (fingerstick) or clinic glucose readings have been documented in any ingested source. Daily home glucose monitoring is essential for insulin titration and hypoglycemia detection.

Related

• Fructosamine — Preferred glycemic marker in setting of AML (not affected by RBC turnover)
• Hba1C — Unreliable in AML; HbA1c improvement likely spurious
• Aml — Active hematologic malignancy; treatment affects RBC lifespan and HbA1c validity

Updated automatically during ingest.