Internal Medicine · Year 3 · from Internal Medicine

Case 2: Type 2 Diabetes - Initiating and Intensifying Therapy

Patient Presentation

A 52-year-old man with type 2 diabetes diagnosed 5 years ago presents for routine follow-up. He is currently on metformin 1000 mg twice daily. He reports good medication adherence but has gained 15 pounds over the past year. He has a history of hypertension and hyperlipidemia. He denies polyuria, polydipsia, or visual changes.

Vital Signs

  • Blood Pressure: 142/88 mmHg
  • Heart Rate: 76 bpm
  • BMI: 34 kg/m²
  • Weight: 104 kg

Physical Examination

  • General: Obese, well-appearing
  • Cardiovascular: Regular rhythm, no murmurs
  • Pulmonary: Clear
  • Abdomen: Obese, non-tender
  • Extremities: No edema, intact sensation to monofilament
  • Skin: Acanthosis nigricans on neck

Laboratory Results

  • HbA1c: 8.4% (goal <7%)
  • Fasting glucose: 168 mg/dL
  • Creatinine: 0.9 mg/dL, eGFR 95 mL/min
  • Urine albumin/creatinine ratio: 45 mg/g (mildly elevated)
  • Lipid panel: LDL 118 mg/dL, HDL 38 mg/dL, TG 210 mg/dL

Clinical Image

Figure 2: Acanthosis nigricans - velvety, hyperpigmented skin changes at the posterior neck, associated with insulin resistance and type 2 diabetes.

Image Source: Educational illustration for teaching purposes.

Questions

  1. According to current guidelines, what is the most appropriate medication to add for this patient with established cardiovascular risk factors?
  • A) Sulfonylurea (glipizide)
  • B) SGLT2 inhibitor (empagliflozin)
  • C) DPP-4 inhibitor (sitagliptin)
  • D) Thiazolidinedione (pioglitazone)
  1. What are the cardiovascular and renal benefits of SGLT2 inhibitors?
  • A) Improved glycemic control only
  • B) Reduced risk of heart failure hospitalization and CKD progression
  • C) Lower LDL cholesterol
  • D) Reduced risk of stroke only
  1. Which medication class would be most beneficial for weight loss in this patient?
  • A) Sulfonylureas
  • B) Insulin
  • C) GLP-1 receptor agonists
  • D) Thiazolidinediones
  1. What is the significance of the elevated urine albumin/creatinine ratio?
  1. What blood pressure goal should be targeted for this diabetic patient?

Answers

  1. B) SGLT2 inhibitor (empagliflozin) - For patients with type 2 diabetes and established cardiovascular disease, heart failure, or CKD, SGLT2 inhibitors are recommended as add-on therapy to metformin regardless of HbA1c due to proven cardiovascular and renal benefits.
  1. B) Reduced risk of heart failure hospitalization and CKD progression - SGLT2 inhibitors have demonstrated reductions in heart failure hospitalization (EMPA-REG, CANVAS, DECLARE trials) and slowed progression of diabetic kidney disease independent of glucose-lowering effects.
  1. C) GLP-1 receptor agonists - GLP-1 RAs (semaglutide, liraglutide) cause significant weight loss (average 5-15% body weight). Sulfonylureas and insulin cause weight gain; TZDs cause fluid retention and weight gain.
  1. Elevated urine albumin/creatinine ratio significance:
  • Indicates early diabetic nephropathy (moderately increased albuminuria: 30-300 mg/g)
  • Strong predictor of progressive kidney disease and cardiovascular events
  • Indication for ACE inhibitor or ARB therapy
  • Supports use of SGLT2 inhibitor for renal protection
  • Should prompt more aggressive glycemic and blood pressure control
  1. Blood pressure goal: <130/80 mmHg for diabetic patients according to ADA guidelines. Tighter control is especially important in those with albuminuria. This patient should be started on an ACE inhibitor or ARB given his hypertension and albuminuria.

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