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Little gems: how hot are you on... diabetes?

Test your knowledge for the nMRCGP with this little gem from GPnotebook

A 54-year-old patient with type 2 diabetes on oral hypoglycaemic treatment (metformin 1g bd, glimepiride 4 mg od) has had a recent HbA1c of 11.4 per cent. His blood pressure is 160/75mmHg and has been an average of 160/80mmol/l on the previous two visits. His lipid profile shows a cholesterol of 6.4 and triglycerides of 8.6mmol (fasting sample) with normal U+Es and an ALT that was raised at twice the normal value.

His other medication is a bendroflumethiazide 2.5mg per day and atenolol 50mg per day. His BMI is 31.2.

Q What would be a suggestion for additional treatment of this man's poor glycaemic control?

A There is the possibility of starting this patient on triple therapy (metformin, sulphonylurea, glitazone). However, it is unlikely that if this man has been compliant with medications, there will be a more than about 1 per cent improvement in his HbA1c.

There is a possibility of increasing doses of both metformin and glimepiride but these doses are reasonable anyway and an increase is unlikely to have significant impact on his HbA1c. It is likely that insulin therapy is the most appropriate next step.

Q What if this man was an HGV lorry driver?

A This makes management much more difficult and the clinician has to take into account social issues as well as clinical issues. At the present time, insulin therapy would be a contraindication to continued accreditation to use an HGV licence.

The next management step will then be determined by the options that are viable to the patient, as well as those that are determined by the clinical indicators.

Q Should this patient be on an aspirin?

A Aspirin 75mg daily is recommended in selected people with diabetes (more than 50 years old, or who are younger but have had the disease for more than 10 years, or who are already receiving treatment for

hypertension), once the blood pressure

has been controlled to at least the audit standard of <150mmhg systolic="" and=""><90 mmhg="">

Q What is the significance of a raised ALT in

diabetic patients?

A Individuals with type 2 diabetes have a higher incidence of LFT abnormalities than individuals who do not have diabetes.

The most commonly abnormal LFT is a raised ALT and is most commonly secondary to non-alcoholic fatty liver disease. However, any diabetes patient found to have a

mild chronic elevation of ALT should have screening for treatable causes of chronic

liver disease – this screening should include hepatitis B, hepatitis C, and hemochrom-atosis, which are found with increased

incidence in type 2 diabetes.

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