What is the best course of treatment for a patient with well-controlled hyperlipidaemia, diabetes mellitus, and hypertension, currently taking metformin (Metformin), perindopril (Ace inhibitor), and statin (HMG-CoA reductase inhibitor)?

Optimal Management for Well-Controlled Diabetes, Hypertension, and Hyperlipidemia

Continue the current medication regimen without changes, as all three conditions are optimally controlled with metformin 500mg twice daily, perindopril 4mg daily, and high-dose statin 80mg daily. 1

Current Status Assessment

Your patient has achieved excellent control across all parameters:

• Blood pressure 127/81 mmHg meets the target of <130/80 mmHg for patients with diabetes and hypertension 1, 2
• HbA1c 44 mmol/mol demonstrates well-controlled diabetes 3
• LDL cholesterol 1.9 mmol/L is well below the target of <2.6 mmol/L (100 mg/dL) for diabetic patients over 40 with cardiovascular risk factors 1
• Total cholesterol 2.9 mmol/L and triglycerides 1.6 mmol/L are both within optimal ranges 1

Medication Continuation Rationale

ACE Inhibitor (Perindopril 4mg)

• Perindopril is the appropriate first-line agent for this patient with diabetes and hypertension, as ACE inhibitors or ARBs are recommended as initial therapy for this population 1, 2
• The current dose is achieving blood pressure targets without requiring additional agents 3
• ACE inhibitors provide renal protection in diabetic patients, particularly important given the slightly reduced eGFR of 86 1
• The albumin-creatinine ratio of 1.7 (normal) confirms no albuminuria, but continued ACE inhibitor therapy helps prevent progression 1

Metformin (500mg twice daily)

• Metformin remains the cornerstone therapy for type 2 diabetes and prediabetes, with proven cardiovascular benefits 3
• The stable HbA1c trend (ranging 43-48) demonstrates effective glycemic control 3
• Important monitoring consideration: Given chronic metformin use, vitamin B12 levels should be checked annually, especially after 4-5 years of therapy, as deficiency risk increases with duration 3

High-Dose Statin (80mg daily)

• Statin therapy is strongly recommended for all diabetic patients over 40 with cardiovascular risk factors (this patient has hypertension, hyperlipidemia, and NAFLD) 1, 4
• The dramatic improvement in lipid profile (LDL decreased from 5.6 to 1.9 mmol/L) demonstrates excellent response 1
• Do not discontinue statins despite the patient's prediabetic state; while statins may slightly increase diabetes risk, cardiovascular benefits far outweigh this concern 3
• Continue monitoring glucose status regularly (already being done with 3-monthly HbA1c) and reinforce lifestyle modifications 3

Critical Monitoring Parameters

Renal Function and Electrolytes

• Monitor serum creatinine/eGFR and potassium at least annually while on ACE inhibitor therapy 1, 2
• The current eGFR of 86 (slightly below normal >90) requires continued surveillance 1
• Sodium and potassium are currently within normal limits 1

Vitamin B12 Screening

• Check vitamin B12 levels annually given chronic metformin use, particularly as the patient approaches 4-5 years of therapy 3
• Higher risk for deficiency exists with prolonged metformin exposure 3

Blood Pressure Monitoring

• Check blood pressure at every routine diabetes visit to ensure sustained control 1
• Current BP of 127/81 mmHg is optimal and below the <130/80 mmHg target 1

Lifestyle Reinforcement

Dietary Modifications

• Reduce sodium intake to 1200-2300 mg/day using a DASH-style dietary pattern 1
• Avoid sugary foods and fizzy drinks to maintain glycemic control 1
• Increase fresh fruits, vegetables, and low-fat dairy products 1

Physical Activity

• Minimum 30 minutes of walking daily is appropriate, though guidelines recommend at least 150 minutes of moderate-intensity aerobic activity weekly distributed over at least 3 days 1

Weight Management

• Weight loss is recommended for this patient with NAFLD and prediabetes to improve insulin sensitivity 3, 1
• Weight reduction will benefit all three conditions (diabetes, hypertension, hyperlipidemia) 1

Additional Cardiovascular Risk Reduction

Aspirin Consideration

• Consider aspirin 75-162 mg daily for primary prevention, as this 58-year-old male with multiple cardiovascular risk factors (hypertension, dyslipidemia, prediabetes, NAFLD) likely has >10% 10-year cardiovascular risk 3
• This represents a potential addition to the current regimen that should be discussed 3

Common Pitfalls to Avoid

• Do not add or switch medications when targets are already achieved - clinical inertia works both ways; unnecessary changes can destabilize well-controlled patients 1
• Do not discontinue statins due to diabetes concerns - the cardiovascular mortality benefit far exceeds the small increase in diabetes risk 3
• Do not combine ACE inhibitors with ARBs or direct renin inhibitors - this increases adverse effects without added benefit 3, 2
• Do not neglect vitamin B12 monitoring in long-term metformin users - deficiency can cause irreversible neuropathy 3

Follow-Up Plan

• Continue 3-monthly blood monitoring including HbA1c, lipid profile, renal function, and electrolytes 1
• Add iron studies as planned for February 2026 1
• Annual comprehensive foot examination should be performed to assess for diabetic neuropathy 3
• Annual dilated eye examination by ophthalmologist or optometrist is recommended for all type 2 diabetic patients 3