What is the best management plan for a patient with poorly controlled Type 2 Diabetes, hypertension, and symptoms suggestive of diabetic neuropathy?

Management Plan for Poorly Controlled Type 2 Diabetes with Neuropathy and Hypertension

The patient requires immediate intensification of diabetes therapy with metformin plus a second-line agent such as an SGLT2 inhibitor, along with lifestyle modifications and treatment of diabetic neuropathy to reduce morbidity and mortality.

Diabetes Management

Glycemic Control

• HbA1c is severely elevated at 114 mmol/mol (target <50), indicating very poor control
• Immediate intervention needed to prevent further complications:
  1. Restart metformin as first-line therapy (despite previous poor compliance) 1
  2. Add SGLT2 inhibitor (empagliflozin) as second-line agent due to:
     • Proven efficacy in reducing HbA1c (0.6-0.8% reduction when combined with metformin) 2
     • Additional benefits of weight reduction and blood pressure lowering 2
     • Renal protection benefits (patient shows early signs of diabetic nephropathy) 2
  3. Consider early insulin therapy if rapid improvement needed given severity of hyperglycemia 1

Lifestyle Modifications

• Eliminate sugary drinks (especially Red Bull) which are significantly contributing to hyperglycemia
• Implement structured exercise program with both aerobic and resistance training 1
• Dietary counseling focusing on carbohydrate management and overall caloric reduction
• Continue weight loss efforts (patient has already lost 22kg, which is positive)

Diabetic Neuropathy Management

Assessment and Treatment

• Left calf cramps with numbness and heaviness indicate diabetic peripheral neuropathy
• Treatment approach:
  1. Optimize glycemic control as first-line management 1
  2. Start duloxetine 60mg daily (FDA-approved for painful diabetic neuropathy) 1
  3. Alternative: pregabalin 300mg daily if duloxetine not tolerated 1
  4. Consider tricyclic antidepressants (amitriptyline 25-75mg) as alternative option 1

Foot Care

• Comprehensive foot examination to assess for ulceration risk 1
• Patient education on daily foot inspection and proper footwear
• Regular podiatry referral for preventive care
• Consider protective footwear if biomechanical abnormalities present 1

Hypertension Management

• Current BP 138/89 mmHg (target <130/80 for diabetic patients)
• Continue current antihypertensive therapy but consider optimization
• Hypertension control is critical as it's a significant modifiable risk factor for diabetic neuropathy progression 3

Additional Complications Management

Diabetic Nephropathy

• Early signs present: microalbuminuria (31 mg/L) and elevated albumin/creatinine ratio (3.6 mg/mmol)
• Ensure ACE inhibitor therapy is optimized 1
• Monitor renal function and albuminuria every 3-6 months 1

Diabetic Retinopathy

• Patient reports worsening eyesight
• Urgent ophthalmology referral for comprehensive eye examination 1
• Optimize both glycemic and blood pressure control to slow progression 1

Bloating and Water Retention

• Evaluate for cardiac causes of edema
• Consider medication side effects
• Monitor for nephrotic syndrome given early diabetic nephropathy

Follow-up Plan

• Review in 2 weeks to assess medication tolerance and adherence
• HbA1c monitoring in 3 months
• Regular screening for all diabetes complications
• Consider diabetes education program to improve self-management skills

Key Pitfalls to Avoid

1. Delaying insulin if rapid improvement not seen with oral agents
2. Ignoring patient's concerns about metformin side effects (consider extended-release formulation)
3. Focusing solely on glucose control while neglecting other cardiovascular risk factors
4. Overlooking depression screening in a patient with multiple complications
5. Failing to address the patient's cultural context as a Māori, which may influence treatment adherence and outcomes

This comprehensive approach addresses the patient's severely uncontrolled diabetes, neuropathic symptoms, and early signs of other diabetic complications to reduce morbidity and mortality risk.