What management plan should be implemented for a patient with poorly controlled type 2 diabetes mellitus, hypercholesterolaemia, mild hyponatraemia, elevated alkaline phosphatase (ALP), and thrombocytosis?

Management Plan for Poorly Controlled Type 2 Diabetes with Multiple Metabolic Abnormalities

Immediate Priority: Intensify Diabetes Management

This patient requires immediate intensification of diabetes therapy given the HbA1c of 84 mmol/mol (9.8%), which places them at high risk for both microvascular and macrovascular complications. 1, 2

Diabetes Treatment Intensification

• Add a second oral agent to the current diabetes medication since monotherapy has clearly failed to achieve glycemic control after adequate trial 2

• The choice of second agent should consider:

  • Metformin as first-line if not already prescribed (appears patient may not be on this based on vague "diabetes medication" description) 2
  • If metformin is already being used, add a sulfonylurea (glimepiride or gliclazide MR preferred for lower hypoglycemia risk) or consider insulin initiation given the severity of hyperglycemia 1
  • With HbA1c >9%, strongly consider initiating insulin therapy immediately rather than adding another oral agent, as this level of hyperglycemia often requires insulin for adequate control 2

• Recheck HbA1c in 3 months to assess response to intensified therapy 2

• Initiate diabetes self-management education covering glucose monitoring, medication administration, hypoglycemia recognition, and dietary modifications 2

Common Pitfall to Avoid

• Do not delay treatment intensification - therapeutic inertia is a major barrier to achieving glycemic control and this patient has clearly demonstrated inadequate control 2, 3

Lipid Management: Optimize Statin Therapy

Increase the current cholesterol medication to at least a moderate-dose statin immediately, as this patient has type 2 diabetes with cardiovascular risk factors (age 76, poorly controlled diabetes, hypertension implied by needs assessment) 1

Specific Lipid Targets and Actions

• Target LDL cholesterol <2.6 mmol/L (100 mg/dL) - current LDL of 3.3 mmol/L requires more aggressive statin therapy 1

• Target total cholesterol <5.0 mmol/L - current level of 5.4 mmol/L is elevated 1

• Target triglycerides <1.7 mmol/L - current level of 2.1 mmol/L is elevated 1

• The American College of Physicians recommends that all patients with type 2 diabetes and cardiovascular risk factors should receive statin therapy for primary prevention 1

• Once initiated, patients should be taking at least moderate doses of a statin 1

• Consider adding a fibrate (fenofibrate) if triglycerides remain elevated after statin optimization and improved glycemic control 1

Monitoring

• Recheck lipid panel in 6-12 weeks after statin dose increase 1
• Do not routinely monitor liver function tests or muscle enzymes unless patient develops symptoms suggesting hepatotoxicity or myopathy 1

Address Mild Hyponatremia (Sodium 134 mmol/L)

Review all current medications for potential SIADH-inducing agents and assess for volume status clinically 2

• Common culprits include sulfonylureas, SSRIs, thiazide diuretics, and carbamazepine
• If asymptomatic and mild (130-134 mmol/L), monitor and address underlying cause rather than aggressive correction
• Recheck sodium in 2-4 weeks after medication review and any adjustments
• Ensure adequate fluid intake is not restricted unnecessarily, but avoid excessive free water intake

Investigate Elevated Alkaline Phosphatase (ALP 141 U/L)

Order gamma-glutamyl transferase (GGT) to determine if ALP elevation is hepatic or bone in origin 2

• If GGT is elevated: suggests hepatobiliary source - consider liver ultrasound to evaluate for fatty liver disease (common in poorly controlled diabetes) or biliary pathology
• If GGT is normal: suggests bone source - consider bone-specific ALP, vitamin D level, and calcium/phosphate levels
• Fatty liver disease (NAFLD/NASH) is extremely common in poorly controlled type 2 diabetes and would be the most likely explanation

Monitor Mild Thrombocytosis (Platelets 464 × 10⁹/L)

Recheck platelet count in 3 months as mild reactive thrombocytosis is common and often transient 2

• Reactive thrombocytosis can occur with inflammation, iron deficiency (though ferritin is normal here), or as a nonspecific finding
• No immediate intervention required unless platelets exceed 600 × 10⁹/L or patient develops thrombotic symptoms
• If persistently elevated >600 × 10⁹/L on repeat testing, consider hematology referral to exclude primary thrombocythemia

Dietary and Lifestyle Modifications

Refer to registered dietitian for individualized medical nutrition therapy focusing on carbohydrate distribution, portion control, and cardiovascular risk reduction 2

• Reduce saturated fat intake to help lower LDL cholesterol 1
• Distribute carbohydrates evenly across meals to improve glycemic control 1
• Recommend at least 150 minutes of moderate-intensity aerobic activity per week plus resistance training twice weekly 2
• Reduce sedentary time throughout the day 2

Follow-Up Timeline

• 2 weeks: Medication review and adjustment confirmation, sodium recheck
• 6-12 weeks: Lipid panel recheck after statin intensification
• 3 months: HbA1c recheck, platelet count recheck, comprehensive metabolic panel including sodium and ALP
• Ongoing: Needs assessment team visit within 3 working days for functional support as already arranged