Answers:
Scenario 1:
54 year old type 2 diabetic on oral hypoglycaemic treatment (metformin 1g bd, glimepiride 4 mg od) has had a recent HbA1C of 11.4%. 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?
- any additional oral hypoglycaemic treatment is likely to improve glycaemic control by about 1%. Consider patient concordance issues. Insulin therapy would generally be indicated in this situation
b) what if this gentleman was a HGV lorry driver?
- insulin therapy would mean revocation of this gentleman's driving licence. This is a recurring problem in primary care where a person has an occupational driving licence and very poor glycaemic control, but the currently most effective treatment will have significant effects on employment options. The GMC has provided guidance if the patient has a medical condition that requires informing of the DVLA and has not done this (GPnotebook reference)
c) should this patient be on an aspirin? His blood pressure needs to be controlled before initiation of aspirin treatment. The HOT study has shown the benefit of aspirin treatment in diabetic patients with hypertension. The whole area of the use of aspirin in diabetics is controversial - see linked item below.
d) should this gentleman have his atenolol continued or stopped? What is the significance of the trial and the study in this respect? What is the significance of the end-point in the ASCOT study?
- there is an increased incidence of diabetes in patients treated with atenolol in comparison to other treatments (LIFE, VALUE, ASCOT studies) and therefore the argument would be to stop/switch betablocker treatment. There are however meta-analyses and systemic reviews which consistently show the lower the blood pressure (by any treatment modalities) the more effective in reducing cardiovascular risk - a reduction in blood pressure by 12/6 mmHg reduces relative stroke risk by 40% and CHD risk by 20%. In this case, there is likely to be a need for multiple therapies to result in blood pressure reduction and so in this first instance the pragmatic answer would be to add in another treatment (although this approach could be debated - the art of medicine!)
- the significance of the endpoints achieved in the ASCOT study is that the study's primary endpoint was not achieved. The study was stopped early because an increase in secondary endpoints. A Drug and Therapeutics review (March 2006,21) has noted that significance in secondary endpoints should be a prompt for further research or to be used to interpret the primary endpoint of a study. This is because the statistical power of a study is based on the primary endpoint of a study
e) what would be a suggestion for the next step in blood pressure control?
- addition of an ACE inhibitor
f) what is the significance of a raised ALT in diabetic patients?
- most likely is secondary to non-alcoholic steohepatitis as a result of diabetes (and poor glycaemic control). Other causes of abnormal LFTs in diabetics would have to be considered (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?
- raised cholesterol will result in consequences of months and years; whereas a significantly raised triglyceride carries the associated risk of pancreatitis. The secondary dyslipidaemia of diabetes is associated with an increase in triglyceride levels and thus improvement in glycaemic control is likely to improve the lipid profile significantly (particularly with respect to triglyceride levels)
- assuming investigation and improvement in liver function tests plus improved glycaemic control, then, in general, a statin would be first-line treatment if triglycerides. NICE have suggested a fibrate as first-line treatment (and possible referral to a specialist clinic) if triglyceride levels > =10mmol/l
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Scenario 2:
JW is a 38 year old female type 2 diabetics.She has four children and during her last 3 pregnancies had gestational diabetes requiring insulin therapy.She is now on treatment with metformin 1g bd and pioglitazone. She drinks no alcohol. Her most recent blood tests revealed a HbA1C of 8.6%, and lipids showing a cholesterol of 8.7 mmol/l and triglycerides of 6.9 mmol/l. Her BMI is 29.6 and her bp is 120/87 mom.Gestational diabetes is a significant risk factor for the future development of type 2 diabetes. a) What is the approximate 15 year risk of developing type 2 diabetes if there is a history of gestational diabetes
b) What would be the next step in management of this lady's type 2 diabetes?
- the alternatives include going to to triple therapy (adding in a sulphonylurea), switching to an insulin plus metformin regime, adding a gliptin or switching to an incretin mimetic and continuing with metformin
- Increasing dose of metformin above 1g bd is unlikely to result in a significant reduction in HbA1c. Other issues such as concordance with medication and diet will need to be addressed. The use of an incretin mimetic plus metformin may also result in reduction in BMI. Switching to insulin plus metformin is likely to result in weight gain in the long term..
c) In poorly controlled type 2 diabetics which regime (once or twice daily) has been shown to me more effective for achieving Glycaemic control
- there is some study evidence that, in patients with poor glycaemic control, twice daily insulin was more effective than a once daily regime in improving glycaemic control
d) If converted to a insulin regime, what would be the ideal target range for BM self-monitoring prior to breakfast