Multifactorial treatment of type 2 diabetes mellitus

A 36-year-old obese patient wants to focus more on therapy for his type 2 diabetes mellitus and weight after his thyroidectomy. He also suffers from hypertension and dyslipidemia, which must also be included in the treatment strategy.

Background

A 36-year-old male patient presented to the diabetology/endocrinology department for postoperative follow-up after thyroidectomy. The patient reported that he had come through the surgery well and that his symptoms had improved significantly. He said he now wants to work on his weight and his diabetes. Type 2 diabetes mellitus had already been diagnosed five years ago and was treated with the sulfonylurea gliclazide (60 mg) and 2x 1000 mg metformin.

Anamnesis and diagnostics

The physical examination revealed a weight of 105.7 kg with a height of 171 cm, which corresponds to a BMI of 35.5 kg/m2 and thus to grade II obesity according to the WHO classification. In addition, systolic and diastolic blood pressure were elevated with values of 149/100 mmHg. Physical examination did not reveal any evidence of diabetic neuropathy.

Furthermore, the patient suffered from pronounced dyslipidemia. HbA1c measurement showed a value of 8.4% and macroalbuminuria was detected as a diabetic secondary complication.

Comment by Prof. Dr. med. Gottfried Rudofsky

A multifactorial approach is often useful in the treatment of patients with type 2 diabetes mellitus. This includes not only glycemic control, but also lifestyle changes such as weight loss and smoking cessation and the best possible adjustment of blood pressure and lipid profile.

The present case shows how such a multifactorial approach can be implemented in practice. For example, the patient had already lost a noticeable amount of weight after three months, blood pressure was in the normal range, and treatment with canagliflozin in combination with metformin significantly optimized HbA1c. In addition, there was an improvement in renal function. However, the present microalbuminuria still requires good blood pressure and blood glucose control. Since this is currently given, the patient’s further treatment can be carried out under the care of a general practitioner.

Therapy

Due to latent hypothyroidism, levothyroxine sodium was increased to 250 µg. Treatment of dyslipidemia was with atorvastatin (80 mg, once daily). To facilitate weight loss, metoprolol, previously used for hypertension treatment, was replaced by ramipril (5 mg, once daily). In addition, gliclazide therapy was stopped and the patient was instead treated with canagliflozin (300 mg, once daily) to achieve better control of type 2 diabetes mellitus. Metformin treatment was maintained.

Present situation

The follow-up after three months showed a very good metabolic control of type 2 diabetes mellitus with an HbA1c value of 7.1%. In addition, the patient had reduced his weight by 6.6 kg. As a result, he now has a BMI of 33.9 kg/m2, which corresponds to grade I obesity according to the WHO classification. Systolic and diastolic blood pressure had normalized with values of 118/82 mmHg. However, the patient complained of an increasing irritable cough, suggesting intolerance to the angiotensin-converting enzyme (ACE) inhibitor. Therefore, hypertension treatment should be switched to an angiotensin receptor blocker, such as candesartan (8 mg, once daily). Blockade of the renin-angiotensin system is also important with respect to treatment of diabetic nephropathy. Here, nephropathy screening showed an albumin/creatinine ratio (ACR) of 121.4 mg/g and albuminuria of 84.6 mg/L. Thus, diabetic nephropathy is now more present in the stage of microalbuminuria (initially macroalbuminuria).

Author: Prof. Dr. med. Gottfried Rudofsky with editorial support from Dr. rer. nat. Christin Döring, IACULIS GmbH
Copyright and responsibility for the content of the patient case rests exclusively with the author.

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