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Interactive diabetes case 17: A 47-year-old patient with newly discovered type 2 diabetes

Interactive diabetes case 17: A 47-year-old patient with newly discovered type 2 diabetes
Author:
Lloyd Axelrod, MD
Section Editor:
David M Nathan, MD
Deputy Editor:
Katya Rubinow, MD
Literature review current through: Jan 2024.
This topic last updated: Dec 19, 2023.

CASE — A 47-year-old woman was found to have hyperglycemia at a health fair when a random blood glucose level was 227 mg/dL (12.6 mmol/L). Several days later, a fasting blood glucose value was 147 mg/dL (8.2 mmol/L). She has no previous history of diabetes, is alarmed by the possibility of having this disorder, and seeks your advice.

The patient has been treated for hypertension for 10 years, currently with amlodipine 10 mg by mouth daily. She was once told that her cholesterol value was "borderline high" but does not know the value.

She denies symptoms of diabetes, chest pain, shortness of breath, heart disease, stroke, or circulatory problems of the lower extremities.

She estimates her current weight at 165 lbs (75 kg). She thinks she weighed 120 lbs (54 kg) at age 21 years but gained weight with each of her three pregnancies and did not return to her nonpregnant weight after each delivery. She weighed 155 lbs one year ago but gained weight following retirement from her job as an elementary school teacher. No family medical history is available because she was adopted. She does not eat breakfast, has a modest lunch, and consumes most of her calories at supper and in the evening.

On examination, blood pressure is 140/85 mmHg supine and 140/90 mmHg upright with a regular heart rate of 76 beats/minute. She weighs 169 lbs, with a body mass index (BMI) of 30.9 kg/m2. Fundoscopic examination reveals no evidence of retinopathy. Vibratory sensation is absent at the great toes, reduced at the medial malleoli, and normal at the tibial tubercles. Light touch sensation is reduced in the feet but intact more proximally. Knee jerks are 2+ bilaterally, but the ankle jerks are absent. The examination is otherwise within normal limits.

Fasting laboratory studies are as follows: glucose 141 mg/dL (7.8 mmol/L); sodium 143 mEq/L, potassium 4.1 mEq/L, chloride 103 mEq/L, and carbon dioxide 25 mEq/L; triglycerides 210 mg/dL (2.4 mmol/L), total cholesterol 222 mg/dL (5.7 mmol/L), high-density lipoprotein (HDL) cholesterol 73 mg/dL (1.9 mmol/L), and low-density lipoprotein (LDL) cholesterol 107 mg/dL (2.8 mmol/L); and glycated hemoglobin (A1C) 8.4 percent. The urine microalbumin/creatinine ratio is 14.3 mg/g.

You conclude that the patient has type 2 diabetes, recently diagnosed. You suspect that the patient has had diabetes for a prolonged period because of evidence of distal sensory neuropathy on examination. Because of the elevated blood pressure values, you begin lisinopril 5 mg daily and plan to stop the amlodipine when the blood pressure is in satisfactory control. You note the lipid values and plan to reassess them when the patient's diabetes is managed satisfactorily.

You counsel the patient about changes in lifestyle. You discuss medical nutrition therapy with the patient with the goal of preventing further weight gain and achieving appropriate weight reduction. You advise her to eat three meals a day (including breakfast), to control the size of portions, to reduce the evening snacks, and to limit her intake of fat. You refer her to a registered dietitian for individualized counseling about medical nutrition therapy and to a certified diabetes educator for teaching about diabetes. You also advise the patient to begin a regular program of exercise, and she agrees to walk for 30 to 35 minutes a day at least five times a week.

What medication would you prescribe for the management of the patient's diabetes?

None. You wish to assess the effects of a trial of lifestyle change including medical nutrition therapy and exercise before adding medication. (See "Interactive diabetes case 17: A 47-year-old patient with newly discovered type 2 diabetes – A1".)

Metformin 500 mg twice a day with breakfast and supper. (See "Interactive diabetes case 17: A 47-year-old patient with newly discovered type 2 diabetes – A2".)

Glyburide 2.5 mg once a day in the morning. (See "Interactive diabetes case 17: A 47-year-old patient with newly discovered type 2 diabetes – A3".)

Pioglitazone 15 mg once a day in the morning. (See "Interactive diabetes case 17: A 47-year-old patient with newly discovered type 2 diabetes – A4".)

Sitagliptin 100 mg once a day in the morning. (See "Interactive diabetes case 17: A 47-year-old patient with newly discovered type 2 diabetes – A5".)

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