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Blood glucose control in adults with type 2 diabetes – case studies Case study one: Mrs AB is aged 82 years old and has recently moved to a care home. Ethnicity = caucasian Past Medical History: Essential hypertension Admisison with congestive cardiac failure 2015 CKD 3 Several recent falls Type 2 diabetes since 2004 Medication: Metformin 1g BD Ramipril 10mg OD Bisoprolol 7.5mg OD Furosemide 40mg OD Atorvastatin 40mg OD Recent blood tests: eGFR 38 (stable over 3 tests in past 12 months) HbA1c 79mmol/mol (9.4%) Total cholesterol 4.2 Recent measurements: BMI 22kg/m2 BP = 114/62 Questions: 1. 2. 3. 4. What individualised HbA1c target would you recommend? What are the options for 2nd line blood glucose lowering medication? What is the best choice and why? What consideration would you give to continuing metformin treatment? Notes for facilitator – case one (Mrs AB) Elderly lady with presumed frailty and falls in care home Stable renal impairment 1. Individualised HbA1c target: Refer group to NICE “patient decision aid” – lots of health problems and age/overall health favours a higher HbA1c target Standard target would 7 – 7.5% but in this case less than 8.5% seems reasonable 2. Options for 2nd line blood glucose lowering medications: Gliclazide – would be the usual next step Pioglitazone DPP4 SGLT – 2 Insulin 3. What is best choice and why? Gliclazide – NO – this lady has a high risk of hypoglycaemia Pioglitazaone – NO - multiple contraindications – heart failure, risk of fractures (age/sex/care home and immobility/falls) and cauton in elderly SGLT-2 – NO – age over 75 and eGFR means contraindicated (will not work!) also on furosemide which would increase risk of hypotension DPP4 – YES – will give 0.5 – 1% HbA1c reduction which will achieve target HbA1c, low hypo risk. At this level of eGFR would need to use a lower dose of sitagliptin 50mg) or use linagliptin (OK with any level of renal impairment) 4. Considerations about metformin: eGFR needs monitorring every 6 months – need to stop metformin if eGFR < 35 At current level of eGFR may consider a lower dose – 500mg BD Consider whether she is at risk of sudden decline in renal function (for example another emergency admission with heart failure) Sick day rules for metformin Metformin does not cause renal damage but patients with low eGFR are at increased risk of fatal lactic acidosis associated with acute illness Case study two: Mr CD is 48 years old and works in security. He is a car driver. Ethnicity = Afrocaribbean Past Medical History: Essential hypertension Type 2 diabetes since 2011 Pancreatitis secondary to gallstones 2015 Backround retinopathy but no other known diabetes complications Medication: Metformin 1g BD Gliclazide 160mg BD Lisinopril 20mg OD Amlodipine 10mg OD Atorvastatin 40mg OD Recent blood tests: eGFR 58 HbA1c 89mmol/mol (10.5%) Total cholesterol 3.8mmol/l ACR 2.1 Recent measurements: BMI 36kg/m2 BP = 138/79 Questions: 1. What individualised HbA1c target would you recommend? 2. What are the options to improve glycaemic control? 3. What would you suggest to him and why? Notes for facilitator – case two (Mr CD) Younger patient in generally good health. First signs of retinopathy. Need to adjust eGFR by 1.21 for ethnicity = 70 1. What individualised HbA1c target would you recommend? Refer to NICE “patient decision aid” – not group 2 driver and aiming for tighter control (young and no known complications) Target is 7% (trigger for intensification of treatment is 7.5%) 2. Options to improve glycaemic control Lifestyle – advice and has he attended desmond or interested in HELP diabetes? This is 2nd intensification and patient has HbA1c > 1% over target so insulin is preferred option. However, need to discuss BMI and risk of weight gain. No occupational reasons not to have insulin therapy. Insulin GLP-1 DPP4 SGLT-2 Pioglitazone 3. What would you suggest and why? Need to explore pros and cons Insulin – YES – as above GLP1 – NO on balance- consider this (although NICE says failed on 3 orals first) however although BMI > 35 he has a h/o pancreatitis (although this was due to gallstones – was gallbladder removed – say not if questioned on this) DPP4 – won’t achieve target SGLT-2 – NO on balance – may be worth a try?? Weight loss possible but unlikely to achieve a reduction in HbA1c of 3% Pioglitazone – NO – probably wont achieve target and weight gain? If there is time discuss basal insulin start, titration etc