Professional Documents
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CASE 1
52-year-old female
Postmenopausal - osteoarthritis of the knees
Sedentary
Smoker - no alcohol
CASE HISTORY
Two months earlier, emergency hospital admission for
suspected acute coronary syndrome (ACS)
Diagnoses made:
No stenotic lesions
Type 2 diabetes
Mixed dyslipidemia
Hypertension
Consultation for:
Intermittent malaise for a month
Recurrent vulvovaginitis
MEDICATIONS
Paracetamol
CLINICAL EXAMINATION
BMI: 30 kg/m 2
Urinary test:
No bacterial urinary infection
Glycemia:
HbA1c: 8.3%
LABORATORY INVESTIGATION
Lipid profile:
HDL cholesterol: 42.4 mg/dL
LDL cholesterol: 208.4 mg/dL
Triglyceride: 92.6 mg/dL
Liver function:
ALAT: 59 IU/L
Thyroid function:
Normal
LABORATORY INVESTIGATION
Cardiovascular function:
Sinus rhythm
No evidence of ischemia
Answer:
1) . BMI
2) . Blood Pressure
3) . Post Prandial Blood Glucose
4) . Albuminuria
5) . Smoking habit
DIAGNOSIS - PROGNOSIS
Q2: Beside the blood glucose, what is your main priority to treat first?
Answer:
1) . Blood Pressure
2) . Pulse pressure
3) . LDL-cholesterol
4) . Smoking habit
5) . None above
DIAGNOSIS - PROGNOSIS
Q3: To treat your type 2 diabetes patients, what is the main level success of
the treatment?
Answer:
1) Body weight reduction
2) HbA1c
3) Micro-macro albuminuria reduction
4) Fasting blood glucose
5) Post-prandial blood glucose
DIAGNOSIS - PROGNOSIS
Q4: In doing aggressive treatment, which risk factor that would be your first
consideration?
Answer:
1) Fasting blood glucose as pre-diabetic state
2) A 4-year duration of diabetes
3) Life expectancy
4) A 30-year duration of diabetes
5) None above
THERAPEUTIC STRATEGY
Q5 : In your opinion, what is the most suitable
therapeutic strategy for this patient?
Answer:
1. Gliclazide MR 60 mg alone od
2. Gliclazide MR 60 mg plus DPP4i
3. DPP4i plus Metformin 500 mg TID
4. Metformin 500 mg plus Gliclazide MR 60 mg
5. Gliclazide MR 60 mg plus basal insulin
CASE 2
PATIENT WITH DIFFICULTY ACHIEVING
GLYCEMIC CONTROL
CASE 2
40-year-old woman
11-year history of type 2 diabetes (T2D)
(1rst consultation 2 years ago)
Positive family history of T2D (her mother)
Previous medications (several years):
metformin 850 mg twice daily
glipizide 5 mg twice daily
Unsatisfactory glycaemic control despite her compliance with
medications as well as lifestyle and dietary restrictions.
(very strict carbohydrate diet)
No history of hypoglycemia
CASE HISTORY
1 month before, switch from glipizide to vildagliptin 50 mg
June 2009 Aug 2010 Sept 2010
Fasting plasma
glucose - 13.1 13.0
(mmol/L)
Pulse 80/minute.
Blood pressure 110/80 mmHg.
young-onset
low body mass index
Difficulty achieving glycemic control despite maximal oral
sulfonylurea and metformin therapy.
Switching her from oral glipizide to vildagliptin resulted in loss of
glucose control.
No past history of severe loss of glycaemic control suggestive of
diabetic ketoacidosis.
THERAPEUTIC DECISION AND STRATEGY
Q1. Is this young woman a candidate for insulin?
Answer:
1. Yes
2. No
3. I dont know
THERAPEUTIC DECISION AND STRATEGY
Patients desire for a trial of oral therapy:
Addition Gliclazide MR 60 mg daily
Answer:
1. Yes
2. No
DISCUSSION
Low risk of hypoglycemia demonstrated7,8
DISCUSSION
In the clinical case, there are not episodes of moderate or severe
hypoglycemia even at HbA1c levels well below 7.0%
Answer:
1. First line treatment
2. Second line treatment
3. SU puts risk of pancreatic exhaustion
4. SU risks of hypoglycemia
5. I dont know
DISCUSSION
Sulfonylureas the first choice for Newly diagnosed
patients & uncontrolled by metformin10
Thank you