Clinical Case : A 48 year old type 2 diabetic


#1

Clinical Case

Mr. S who is a 48 year old type 2 diabetic patient diagnosed about eight months ago. He weighs 88 kgs and his BMI is 25 kg/m2. His blood pressure during his physical exam is 144/98mm of Hg and his A1c is 8.2% with a fasting blood sugar of 138 and the PPBS of 192 mg/dl. He is attempting to loose weight with regular walks and healthier food choices but there has not been much progress. He is a non smoker and he doesn’t have a family history of cardiovascular disease. The rest of his physical exam is otherwise unremarkable. His current medicines include metformin 1500mg per day and telmisartan 40 mg and rosuvastatin 10mg.

So what would be your choices in managing this patient further?


#2

He is young and should have a target A1c of less than 6.5 and he is at 8.2%, so I want whatever the next agent I give him to give me a fairly robust A1c reduction. I probably wouldn’t add a DPP-4 inhibitor because I might not get the A1c reduction I am looking for. You could add it, but then you would probable need a third drug.

I wouldn’t use a sulfonylurea like glimipride in this case if I didn’t have to because I don’t want to cause hypoglycaemia and weight gain.

You could add a GLP-1 receptor agonist like liraglutide but often times people prefer the oral choice before they go on to injections.

In this case, I would like to add a SGLT-2 inhibitor like empagliflozin. He can loose some weight. His blood pressure is elevated and one would hope that the SGLT-2 would help with that but I would say keep an eye on that because if it doesn’t come down sufficiently with SGLT-2, I would stress that we nee to adequately improve the BP control with other drugs.