GEM - difficult diabetes educational module - part one - clinical cases

Scenario 1:

54 year old type 2 diabetic on oral hypoglycaemic treatment (metformin 1g bd, glimepiride 4 mg od) has had a recent HbA1c (click for more information about HbA1c) of 11.4% (101 mmol/mol). His blood pressure is 160/75 mom and has been an average of 160/80 on the previous two visits. His lipid profile shows a cholesterol of 6.4 and triglycerides of 8.6 mmol (fasting sample) with normal U+Es and an ALT that was raised at twice of the normal value. His other medication is a bendroflumethiazide 2.5 mg per day and atenolol 50 mg per day. His BMI is 31.2.

• a) what would be a suggestion for additional treatment of this gentleman's poor glycaemic control?
• b) what if this gentleman was a HGV lorry driver?
• c) should this patient be on an aspirin? GPnotebook reference click here
• d) should this gentleman have his atenolol continued or stopped? What is the significance of the LIFE (click here for more information) trial and the ASCOT (click here for more information) study in this respect? What is the significance of the end-point in the ASCOT study? GPnotebook reference click here
• e) what would be a suggestion for the next step in blood pressure control?
• f) what is the significance of a raised ALT in diabetic patients? GPnotebook reference click here
• g) which part of this gentleman's lipid profile is the most urgent to address? If further investigations are negative then what would be the suggestion for first-line treatment?

answers click here

Scenario 2:

JW is a 38 year old type 2 diabetic. She has four children and during her last 3 pregnancies has had gestational diabetes requiring insulin therapy. She is now on treatment with metformin 1g bd and pioglitazone 45mg od. She drinks no alcohol. Her most recent blood tests revealed a HbA1C of 8.6% (70 mmol/mol). Her BMI is 29.6.

Gestational diabetes is a signficant risk factor for possible future development of type 2 diabetes. What is the approximate 15 year risk of developing type 2 diabetes if there is a history of gestational diabetes (GPnotebook reference click here for further information):

• (i) 5%
• (ii) 33%
• (iii) 50%
• (iv) 80%

What would be the next step in management of this lady's type 2 diabetes?

• (i) increase dose of metformin to 1g tds
• (ii) add a sulphonylurea e.g. gliclazide 80 mg od
• (iii) switch to insulin therapy alone
• (iv) switch to insulin therapy plus glitazone
• (v) switch to insulin therapy plus metformin
• (vi) add a glitpin
• (vii) switch to incretin mimetic

c) in poorly controlled type 2 diabetes which regime (once or twice daily) has been shown to be more effective for achieving glycaemic control?more information click here

d) if converted to an insulin regime, what would be the ideal target range for pre-breakfast BMs?

• (i) 4-7
• (ii) 6-10
• (iii) 7-10

Other considerations:

• exercise and weight reduction
• does this lady smoke
• other risk factors e.g. lipid levels
• the health beliefs of the patient
• are there concordance problems
• signficance of pregnancy and use of oral hypoglycaemic agents (GPnotebook reference click here)

answers click here