One Patient's Journey to Control Diabetes

WHEN MARIA ILBARA WAS FIRST DIAGNOSED WITH the beginnings of Type 2 diabetes in 2009, she was able to keep her blood sugar levels under control for years by taking an oral medication called metformin. Even though diabetes has no cure, she felt confident in her ability to manage it in order to prevent complications. At 62, the physical therapy aide considered herself healthy; she continued to work and maintained an active lifestyle.

That all changed in 2009, when Ilbara went to see her primary care physician for a routine Pap smear and mammogram. Her doctor noticed some raised patches on the skin of her chest and back, and how red her hands were.

Those patches were xanthomas, a telltale sign of a condition called primary biliary cirrhosis, a chronic disease in which the small bile ducts in the liver become injured and inflamed and are eventually destroyed. When there are no bile ducts, bile builds up and causes liver damage.

Many people with this condition — and Ilbara was one — don’t have symptoms until the disease is fairly advanced. Her primary care physician referred her to a liver specialist at Loma Linda right away. Further testing revealed that Ilbara’s liver damage was so severe that she required a liver transplant. She received a donor liver on May 31, 2018.

Fortunately, her recovery from the transplant surgery was uneventful. However, her diabetes took a turn for the worse.

“Mrs. Ilbara developed what is known as post-transplant diabetes,” explains Helen Baron, MD, Endocrinologist, Eisenhower Health, who specializes in diabetes. “She went from having a form of Type 2 diabetes that’s pretty straightforward and easily controllable to a much more complex disease and treatment regimen that required four insulin injections a day. (See sidebar on page 65 for an overview of the five different types of diabetes.)

“Post-transplant diabetes is a separate and unique form of diabetes that’s referred to as category 4 or other type of diabetes mellitus, and as many as 25 to 50 percent of transplant patients develop it — even if they didn’t have diabetes before their transplant, like Mrs. Ilbara,” she continues. “It’s due to the immunosuppressive medications that transplant patients must take for life. These include steroids, which have a nasty side effect of increasing insulin resistance and therefore blood sugars. Other drugs that transplant patients must take also make their diabetes more difficult to control.”

With post-transplant diabetes mellitus, Ilbara had much more trouble keeping her blood sugar levels within the healthy range, unlike before her transplant. She was having a particularly hard time managing her new insulin regimen in relation to meals. Her primary care physician referred her to Eisenhower’s Diabetes Education Services for expert guidance and support.

“Mrs. Ilbara was new to using both long-acting and fast-acting insulins,” says Sherri Mason, a Certified Diabetes Educator who is also a Registered Dietitian. Long-acting insulin can control blood sugar for an entire day, similar to the action of insulin that’s normally produced by the pancreas in someone without diabetes. Short-acting insulin is injected before a meal to handle a rise in blood sugar from eating.

“But she had been injecting her mealtime insulin after eating due to fear of dropping her blood sugar too low,” Mason continues. “She also complained of feeling shaky between meals, which she assumed was due to low blood sugar levels. But we checked her blood sugar while she was in the office and it was over 250 mg/dL. A healthy range between meals for someone with diabetes is 80 to 130 mg/dL.”

Ilbara also spent time with Diabetes Educator Emily Groves-Nemati, MSN, RN, PHN, who taught her how to use a continuous glucose monitor, a device used to monitor blood sugar levels day and night by collecting readings automatically every few minutes. The system measures glucose levels through a small sensor — the size of two stacked quarters — applied to the back of the upper arm. It provides real-time readings for up to 10 days, around the clock. And it eliminates the challenge of traditional glucose monitoring which requires fingersticks several times a day.

“We also provided ongoing emotional support and encouragement to help Mrs. Ilbara continue with her diabetes selfmanagement long term,” says Diabetes Education Services Manager Marielena Cid, MSN, RN, CDE, PHN.

“They have taught me a lot,” Ilbara says. “I’ve learned about the foods I can and can’t eat — no more pretzels, but more chicken and vegetables — and about eating smaller portions. I know when to take my insulin and how to use the continuous glucose monitor. I walk a bit each day. And my numbers are staying where they should.”

Now 72, married for nearly 50 years and with five children, 17 grandchildren and four great-grandchildren, she is grateful for the care and education she has received. “I don’t have complications from my diabetes or my transplant, and the only medicines I take are insulin and the ones for antirejection,” she says. “Given everything, I feel happy and healthy.”