What are the recommendations for a patient with poorly controlled type 2 diabetes and hyperlipidemia?

From the Guidelines

Based on Chanel's case, I strongly recommend a comprehensive approach to improve her diabetes management, focusing on medication optimization, lifestyle modifications, and emotional support to address her suboptimal glycemic control (HbA1c 102 mmol/mol) and reduce her risk of long-term complications, as supported by the most recent guidelines on lifestyle management in diabetes 1.

To achieve this, the following steps should be taken:

• Continue with her current medications (Metformin 1g twice daily, Protaphane insulin twice daily, and Victoza/liraglutide at night) while emphasizing consistent adherence, particularly for evening doses.
• Utilize the CGM trial with Freestyle Libre 2 Plus to help her understand her glucose patterns and how they relate to her diet and medication timing.
• For lifestyle changes, start with small, achievable physical activity goals through the LHC referral, gradually building up to 150 minutes of moderate exercise weekly, as recommended for individuals with type 2 diabetes to improve glycemic control and reduce cardiovascular risk 1.
• Regarding diet, focus on balanced meals with protein, fiber, and healthy fats to manage glucose spikes, rather than strict dieting, and consider meal preparation strategies that work within her challenging home environment, such as preparing and freezing healthy portions, as suggested by nutrition principles and recommendations in diabetes 1.
• For emotional eating, developing alternative coping mechanisms for stress and sadness would be beneficial, and mental health support may be valuable given her emotional response to her condition and history of pregnancy losses.
• The potential transition to Ryzodeg insulin should be evaluated at her follow-up appointment on May 28th, based on CGM data and adherence patterns, considering the importance of individualized insulin therapy and the role of insulin in achieving optimal glycemic control 1.

Key considerations include:

• The importance of lipid control in the management of type 2 diabetes mellitus, as highlighted by the American College of Physicians guideline 1, which recommends at least moderate doses of a statin for patients with type 2 diabetes.
• The need for a comprehensive approach that addresses not only glycemic control but also cardiovascular risk factors, such as dyslipidemia and hypertension, as emphasized by the standards of medical care in diabetes-2018 1.
• The role of nutrition therapy in diabetes management, including the recommendation for an individualized MNT program and the emphasis on lifestyle strategies to reduce glycemia, dyslipidemia, and blood pressure 1.
• The importance of regular physical activity and weight management in improving glycemic control and reducing the risk of long-term complications, as supported by the evidence on lifestyle management in diabetes 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Recommendations

Based on the provided information, the following recommendations can be made for Chanel:

• Medication Adherence: Chanel's inconsistent medication adherence, particularly with evening doses, should be addressed. Studies such as 2 highlight the importance of treatment adherence in achieving better glycemic control.
• Insulin Regimen: Considering Chanel's current insulin regimen and her preference for oral medications over injections, a potential transition to a fixed combination of insulin degludec and liraglutide (IDegLira), as studied in 3 and 4, could be explored to simplify her treatment and improve glycemic control.
• Continuous Glucose Monitoring (CGM): The use of CGM, as mentioned in the plan, can provide valuable insights into Chanel's blood glucose patterns. Studies like 5 and 2 demonstrate the benefits of CGM in managing diabetes and its potential to inform treatment decisions.
• Lifestyle Interventions: Given Chanel's desire to increase physical activity and her struggles with emotional eating, referrals to support services such as the one mentioned (LHC referral) can help her develop healthier habits. Dietary discussions, as initiated, should continue to focus on balanced meals and managing cravings.
• Mental Health Support: The emotional aspect of Chanel's diabetes management, including her past experiences and current distress, should not be overlooked. As suggested, mental health support could be beneficial if her distress persists, considering the psychological impact of diabetes and pregnancy losses.
• Family and Environmental Factors: Chanel's home environment, with family members having diabetes and not following healthy eating patterns, poses a challenge. Involving family members in her care plan or providing resources on healthy eating for the whole family could be beneficial in creating a more supportive environment.

Key Considerations

• Glycemic Control: Improving Chanel's glycemic control is crucial, given her suboptimal HbA1c levels. Medication adjustments, lifestyle changes, and continuous monitoring will be key in achieving this goal.
• Future Pregnancy Plans: Chanel's desire to be healthier for a potential future pregnancy underscores the importance of achieving good glycemic control and adopting healthy lifestyle habits now.
• Comprehensive Care: Chanel's care should be comprehensive, addressing not only her diabetes management but also her mental health, lifestyle, and environmental factors to ensure sustainable and meaningful improvements in her health.