How to manage a patient with uncontrolled Type 2 Diabetes Mellitus (T2DM) and Hypertension?

Management of Type 2 Diabetes with Uncontrolled HbA1c and Microalbuminuria

For this patient with uncontrolled Type 2 Diabetes (HbA1c 61 mmol/mol), hypertension, microalbuminuria, and dyslipidemia, treatment intensification with an SGLT2 inhibitor (such as empagliflozin) should be added to the current metformin therapy to improve glycemic control and provide renal protection.

Current Clinical Status Assessment

• HbA1c: 61 mmol/mol (target <50 mmol/mol) - indicates suboptimal glycemic control
• Blood Pressure: 135/83 mmHg (target <130/80 mmHg for diabetic patients) 1
• Lipids: Total cholesterol 5.1, Triglycerides 2.1 (both elevated)
• Renal Function: eGFR 89 (normal), but with microalbuminuria (ACR 8.2 mg/mmol)
• Current Medications: Metformin 1g BD, Perindopril 4mg daily, Felodipine 2.5mg nocte, Atorvastatin (dose not specified)

Diabetes Management Plan

1. Medication Adjustment

• Continue Metformin: Maintain current dose of 1g twice daily as foundation therapy 1, 2
• Add SGLT2 inhibitor: Initiate empagliflozin 10mg daily
  • Provides glycemic control with HbA1c reduction of 0.6-0.8% 3
  • Offers nephroprotection for patients with microalbuminuria 1
  • Reduces cardiovascular risk and provides renal protection 1, 2

2. Blood Pressure Management

• Current regimen: Perindopril 4mg daily + Felodipine 2.5mg nocte
• Target: <130/80 mmHg for diabetic patients 1
• Recommendation: Continue current antihypertensive therapy as BP is approaching target, but monitor closely

3. Lipid Management

• Optimize statin therapy: Ensure atorvastatin dose is at least 40-80mg (high intensity) 2
• Target: LDL-C <1.8 mmol/L for patients with diabetes and cardiovascular disease 1

4. Lifestyle Modifications

• Dietary counseling: Address reported cravings for sweet foods with specific dietary strategies
• Structured education program: Implement group-based education to improve diabetes knowledge and self-management 1
• Physical activity: Recommend moderate-to-vigorous exercise for at least 150 minutes per week

Monitoring Plan

• HbA1c: Recheck in 3 months to assess response to therapy 2
• Blood pressure: Continue home monitoring and office checks
• Renal function: Monitor eGFR and potassium after initiating SGLT2 inhibitor
• Urine ACR: Follow up in 3-6 months to assess impact on microalbuminuria

Rationale for SGLT2 Inhibitor Addition

The addition of an SGLT2 inhibitor is strongly supported by current guidelines for several reasons:

1. Glycemic control: When metformin monotherapy fails to achieve target HbA1c, dual therapy is recommended 1

2. Renal protection: SGLT2 inhibitors have demonstrated significant nephroprotection in patients with microalbuminuria 1

   • The 2019 ESC Guidelines specifically recommend SGLT2 inhibitors for patients with eGFR 30-90 ml/min/1.73m² 1
   • Empagliflozin has shown a 30% reduction in renal endpoints 1

3. Cardiovascular benefits: SGLT2 inhibitors reduce cardiovascular risk in patients with T2DM 1, 2

Important Considerations and Potential Pitfalls

• Monitor for euglycemic DKA: A rare but serious complication of SGLT2 inhibitors 2
• Genital mycotic infections: Counsel patient about increased risk and hygiene measures
• Volume depletion: Monitor for symptoms, especially with concurrent diuretic use
• Avoid in severe renal impairment: Not a concern for this patient with eGFR 89

Alternative Approaches

If SGLT2 inhibitors are contraindicated or not tolerated:

1. GLP-1 receptor agonist: Consider adding liraglutide or semaglutide, which also offer renal protection 1
2. DPP-4 inhibitor: Less potent but well-tolerated option for HbA1c reduction
3. Insulin therapy: Consider if HbA1c remains >8% despite dual or triple oral therapy 1, 4

The evidence strongly supports treatment intensification for this patient, as significant reductions in HbA1c were evident at 6 months with therapy intensification compared to non-intensification in real-world settings 5.