How to manage a non-adherent patient with T2DM, Hypertension, and Hyperlipidaemia presenting with Hyperglycemia and Hypertension?

Management of Non-adherent Patient with T2DM, Hypertension, and Hyperlipidemia

This patient requires immediate reinitiation of medication therapy for diabetes, hypertension, and hyperlipidemia, with priority given to controlling hyperglycemia (blood glucose 20 mmol/L) and hypertension (BP 158/89 mmHg) to reduce mortality and morbidity risk.

Initial Assessment and Management

Hyperglycemia Management

• Random blood glucose of 20 mmol/L indicates severe hyperglycemia requiring immediate intervention
• For patients with HbA1c ≥10% (which this patient likely has based on glucose level), guidelines recommend:
  • Initiate insulin therapy (basal + prandial insulin) 1
  • Target fasting glucose 4.4-7.0 mmol/L and post-prandial <10.0 mmol/L 1
  • Consider adding GLP-1 receptor agonist to the regimen for better adherence and greater HbA1c reduction 1

Hypertension Management

• Current BP 158/89 mmHg requires pharmacological treatment
• For patients with BP ≥160/100 mmHg, initial treatment with two antihypertensive medications is recommended 2
• For BP between 140/90 mmHg and 159/99 mmHg (as in this patient), begin with a single agent 2
• Recommended first-line therapy:
  • ACE inhibitor or ARB (particularly given comorbid diabetes) 2
  • Target BP goal <130/80 mmHg 2

Hyperlipidemia Management

• Statin therapy is recommended for most persons with diabetes aged 40 years or older 2
• High-intensity statin therapy is preferred unless contraindicated 2

Addressing Non-adherence

1. Identify barriers to medication adherence:

   • Discuss reasons for non-adherence (cost, side effects, travel issues)
   • Minimize cost of therapy by using generic medications when possible 2
   • Consider once-daily dosing regimens and fixed-dose combinations to improve adherence 2

2. Patient education:

   • Explain the relationship between uncontrolled diabetes, hypertension, and hyperlipidemia and increased risk of complications
   • Emphasize that T2DM with hypertension and hyperlipidemia significantly increases mortality risk 3, 4
   • Discuss that weight loss reported by patient could be a symptom of uncontrolled diabetes

3. Monitoring plan:

   • Schedule follow-up within 1-2 weeks to assess response to therapy
   • Arrange for comprehensive laboratory testing:
     • HbA1c
     • Lipid panel
     • Kidney function (eGFR and urine albumin-to-creatinine ratio)
     • Liver function tests

Comprehensive Care Plan

Medication Recommendations

1. Diabetes:

   • Start with basal insulin (e.g., glargine or detemir) plus rapid-acting insulin with meals
   • Consider adding metformin if not contraindicated by kidney function
   • Consider SGLT2 inhibitor if eGFR allows (provides cardiovascular and renal benefits) 2

2. Hypertension:

   • Initiate ACE inhibitor or ARB (e.g., lisinopril or valsartan) 2
   • If BP remains uncontrolled, add calcium channel blocker or thiazide-like diuretic 2
   • Monitor serum creatinine/eGFR and potassium levels after initiating ACE inhibitor or ARB 2

3. Hyperlipidemia:

   • Start high-intensity statin (e.g., atorvastatin 40-80 mg or rosuvastatin 20-40 mg) 2

Screening for Complications

• Diabetic kidney disease: Measure urine albumin-to-creatinine ratio and eGFR 2
• Retinopathy: Refer for comprehensive eye examination 2
• Neuropathy: Perform foot examination using 10-g monofilament testing 2
• Cardiovascular disease: Assess for symptoms of coronary artery disease and heart failure 2

Lifestyle Modifications

• Dietary counseling focusing on reduced caloric intake, carbohydrate counting, and portion control
• Regular physical activity (aim for 150 minutes of moderate-intensity exercise per week)
• Smoking cessation (patient quit in 2011, reinforce continued abstinence)
• Limit alcohol consumption (already minimal)

Follow-up Plan

• Weekly phone check-ins for insulin dose adjustments
• In-person visit in 2 weeks to assess response to therapy
• Laboratory tests in 3 months to evaluate HbA1c and other parameters
• Quarterly visits thereafter until stable

Pitfalls and Caveats

• Avoid clinical inertia: Do not delay insulin initiation despite patient's non-adherence history
• Beware of hypoglycemia: Start with conservative insulin doses and educate patient on hypoglycemia recognition and management
• Monitor for medication interactions: Particularly when reintroducing multiple medications simultaneously
• Address acute symptoms: Current scratchy throat and cough should be evaluated but are likely unrelated to diabetes management
• Consider social determinants: Frequent travel may require simplified regimen and portable medication options