How should a typical diabetic patient, 55-year-old, obese, with hypertension, dyslipidemia, and reduced renal function be treated?
Therapy recommendation
In the following, I would like to present my recommendations for the optimal treatment of the 55-year-old, newly diagnosed T2DM patient presented in the video above.
In addition to his T2DM, the patient suffers from visceral obesity, arterial hypertension, classic dyslipidemia, and chronic renal insufficiency with microalbuminuria, among other conditions. His HbA1c level was 10.5% at the time of presentation.
Overall, the patient has a high to very high cardiovascular risk, which means that his LDC-C target value according to the current guidelines is >1.8 and >1.4 mmol/l, respectively. In addition, a reduction in systolic blood pressure to 120 – 140 mmHg and diastolic blood pressure to 70 – 80 mmHg should be achieved.
I would recommend a triple combination of metformin, a GLP-1 RA, and an SGLT-2 inhibitor as the optimal therapy for this patient. Unfortunately, this triple therapy is not yet reimbursed by health insurers, although its benefits in terms of 3-point MACE, severe hypoglycemia, and total mortality have been demonstrated quite clearly in a Danish real-world study [1].
Considering the reimbursement situation and the patient’s preferences, I would treat the patient with canagliflozin (Invokana®, 100mg, 1-0-0) and with sitagliptin/metformin (Janumet®, 50mg /1000mg, 1-0-1) to better manage their diabetes. Since T2DM has only recently been discovered and the patient does not yet want injection therapy, a GLP1-1 RA is rather out of the question at this point.
For treatment of hypertension and dyslipidemia, I recommend atorvastatin/perindopril/amlodipine (Triveram®, 40mg/10mg/10mg, 1-0-0).
In addition, the patient should present for follow-up after one month.
References
1. Jensen, M.H., et al, Risk of Major Adverse Cardiovascular Events, Severe Hypoglycemia, and All-Cause Mortality for Widely Used Antihyperglycemic Dual and Triple Therapies for Type 2 Diabetes Management: A Cohort Study of All Danish Users. Diabetes Care, 2020. 43(6): p. 1209-1218.
Explanations: Prof. Roger Lehmann, MD, with editorial assistance from Dr. rer. nat. Jennifer Keim, IACULIS GmbH. Copyright and responsibility for the content of the patient case rests exclusively with the author.
