The following scenarios are fictitious but similar to those experienced by real patients and are designed to help you reflect on what you have learnt after reading the article. They could also be used for group discussion in an education or practice meeting. There are no right or wrong answers but some pitfalls to avoid.

Icon used to indicate Guidelines in Practice test and reflect content

The following case studies written by Professor Peter Grant relate to the expert article, Diabetes: adapt management to account for cardiovascular disease risk.

Case 1: Ian, age 59 years

Ian has been diagnosed with type 2 diabetes for 5 years. He currently takes metformin 850 mg b.d. and gliclazide 80 mg o.d. for glycaemic control and his HbA1c is currently 8.5%. He also takes simvastatin 40 mg o.d. and his total cholesterol is 5.9 mmol/l with a low-density lipoprotein cholesterol (LDLC) of 2.8 mmol/l. His blood pressure (BP) is consistently 146/95 mmHg with an estimated glomular filtration rate (eGFR) of 65 ml/min. His electrocardiogram (ECG) is normal at rest, but he is starting to complain of indigestion-like pain on walking that subsides at rest.

Questions for reflection

  1. What level of cardiovascular (CV) risk would you attribute to this patient?

  2. Is there any requirement to optimise glycaemic control, and why?

  3. Would you add a further hypoglycaemic agent and, if so, which would you choose?

  4. Bearing in mind the level of CV risk you have determined, how would you approach lipid and BP management?

Reveal how to manage this patient

This patient is at very high risk of CV disease and, as is commonly the case, he is sub-optimally treated across the spectrum of CV risk. He requires improved glycaemic control both to reduce risk of microvascular complications and, along with other CV therapies, to improve CV outcomes. In this case we should be aiming for an HbA1c of as close to 7% as possible, while avoiding hypoglycaemia. It would be appropriate, in view of the level of CV risk and the eGFR, to add an sodium-glucose co-transporter 2 (SGLT-2) inhibitor or glucagon-like peptide-1 receptor agonist (GLP-1 RA) to current therapy. The lipid therapy needs optimising to a level that brings the LDLC down towards 1.4 mmol/ml; this could be achieved by using a more powerful statin such as atorvastatin at optimal doses, with the addition of ezetimibe if required. His blood pressure needs managing as it is consistently running too high. It would be appropriate in view of the very high CV risk to commence aspirin therapy. Finally, this man needs further investigations with respect to his chest pain.

Case 2: Joan, age 53 years

Context

Joan presented 5 years ago with impaired glucose tolerance and has recently been diagnosed with frank type 2 diabetes. Her HbA1c is 7.5% with a fasting blood glucose of 8 mmol/ml, total cholesterol is 5.4 mmol/l with an LDLC of 2.2 mmol/l. She has microalbuminuria on dipstick testing and a resting BP of 145/85 mmHg. She currently takes no therapy other than occasional paracetamol and alginic acid for indigestion. She came to the practice complaining of discomfort in her legs while walking in cold weather. On examination, her leg pulses are present but diminished below the knee.

Questions for reflection

    1. What level of CV risk would you attribute to this patient?

    2. How would you manage this patient’s diabetes?

    3. How would you respond to her lipid results?

    4. Are any other investigations warranted?

    5. What other treatments should be considered?

Reveal how to manage this patient

Assuming that the clinical findings indicate the presence of peripheral vascular disease, this patient will be at very high risk of CV disease. It would be important to investigate her CV system more thoroughly to evaluate whether she has a definitive diagnosis of peripheral vascular disease, but also to evaluate whether there is evidence of coronary artery disease. It would also be important to check her eGFR before commencing treatment.

This patient is newly diagnosed with type 2 diabetes and is drug naïve. On the basis of her vascular risk, the guideline would recommend commencing either a sodium-glucose co-transporter 2 (SGLT-2) inhibitor or a glucagon-like peptide-1 receptor agonist (GLP-1 RA) for the management of diabetes as first line. The ESC/EASD guideline recommends that this patient is treated aggressively with lipid lowering therapy aiming to achieve an LDLC of 1.4 mmol/l, aspirin, and blood pressure management.

Case 3: Omar, age 48 years

Context

Omar was recently diagnosed with type 2 diabetes. His HbA1c is currently 7.9%, and has a total cholesterol of 5.0 mmol/l, an LDLC of 2.0 mmol/l, and triglyceride of 2.6 mmol/l. His blood pressure is 135/85 mmHg. There is no evidence of microalbuminuria and his retinal screening is normal. His BMI is 28.4 kg/m2. He is currently on no therapy.

Questions for reflection

  1. What level of CV risk would you attribute to this patient?

  2. How would you manage this patient’s diabetes?

  3. What is the significance of the raised triglyceride levels?

  4. Would this patient currently benefit from aspirin therapy?

  5. Are any further investigations warranted?

Reveal how to manage this patient

This patient would currently be determined to have a moderate CV risk according to the guideline. As a drug naïve patient at moderate risk he would warrant lifestyle advice and the addition of metformin as first line, followed by either a sodium-glucose co-transporter 2 (SGLT-2) inhibitor, glucagon-like peptide-1 receptor agonist (GLP-1 RA) or other current therapies if good HbA1c control is not maintained. The elevated triglyceride levels could be an indication of excess alcohol consumption and this should be discussed, but in the absence of hard evidence it probably indicates the presence of underlying insulin resistance which further supports the use of metformin. Aspirin is not warranted in this patient, who is only at moderate CV risk (formerly classified as primary prevention) and the recent evidence confirms the risk/benefit of aspirin in these circumstances does not justify its use. Further baseline CV investigations, resting ECG, B-type natriuretic peptide (BNP), cardiac echocardiogram in the presence of any symptoms of excess tiredness or dyspnoea, eGFR, and gamma glutamyltransferase (GT) would be useful.