Should the current medication regimen be continued for a patient with type 2 diabetes mellitus (T2DM), hypertension, and hyperlipidemia, given their recent blood test results and low medication supply?

Medication Regimen Continuation and Optimization

Continue the current medication regimen with medication refill as requested, while continuing metformin 500mg BD as the cornerstone of diabetes management, and ensure regular 3-6 month medication reviews to optimize therapy based on evolving clinical status. 1

Diabetes Management Assessment

The patient's diabetes control is acceptable with HbA1c of 53 mmol/mol (7.0%), showing minimal change from the previous reading of 54 mmol/mol. 1

• Metformin should be continued indefinitely as it is the preferred first-line agent for type 2 diabetes and should be maintained as long as tolerated and not contraindicated, with other agents added to metformin rather than replacing it. 1
• The current dose of metformin 500mg BD (1000mg daily) is at the lower end of the therapeutic range; optimal dosing is typically 2000mg daily in divided doses if tolerated. 2
• With eGFR of 75 mL/min/1.73m², metformin is safe to continue as the FDA-approved threshold is eGFR ≥30 mL/min/1.73m². 1

Consider intensification at next review: While the HbA1c is at target, the American Diabetes Association recommends that medication regimens should be reevaluated every 3-6 months and adjusted as needed. 1 Given this patient's cardiovascular risk profile (hypertension, hyperlipidemia, age 64), consideration should be given to adding an SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit, independent of current A1C level. 1

Cardiovascular Medication Assessment

The blood pressure is well-controlled at 118/77 mmHg, which is below the target of <130/80 mmHg for patients with diabetes. 1

• Continue the current antihypertensive regimen (losartan 100mg OD, amlodipine 5mg OD, propranolol 10mg BD) as blood pressure is at goal. 1
• The combination of an ARB (losartan), calcium channel blocker (amlodipine), and beta-blocker (propranolol) is appropriate for this patient with diabetes and represents guideline-concordant therapy. 1
• Losartan (ARB) is particularly appropriate as ACE inhibitors or ARBs are recommended as part of the regimen for patients with diabetes and hypertension. 1

Lipid management is excellent: Total cholesterol 3.0 mmol/L, LDL 2.0 mmol/L, HDL 1.30 mmol/L, and triglycerides 1.5 mmol/L all meet or exceed targets for a patient with diabetes. 1

• Continue atorvastatin 20mg nocte as statins are the first-line agents for LDL lowering in diabetes and reduce cardiovascular events and death. 1
• The current lipid profile suggests no need for intensification at this time. 1

Aspirin Therapy Consideration

The patient is currently on aspirin 100mg every other day (EOD).

• Standard dosing for cardiovascular prevention is 75-162mg daily, not every other day. 1
• For a 64-year-old patient with diabetes, hypertension, and hyperlipidemia, aspirin 75-162mg daily is recommended as primary prevention given the 10-year cardiovascular risk is likely >10%. 1
• Consider changing to daily dosing (75-100mg daily) rather than EOD at the next medication review. 1

Medication Refill and Adherence

Approve the medication refill immediately given only 8-9 days of supply remaining and the 2-3 day preparation time for blister packs. 1

• Medication adherence is critical for effectiveness of therapy, and ensuring uninterrupted supply is essential to prevent treatment gaps. 1
• The blister pack system may improve adherence but requires advance planning to avoid supply interruptions. 1

Medication Regimen Complexity

This patient is on 10 medications with varying dosing frequencies (monthly, daily, twice daily, every other day), which represents moderate to high medication regimen complexity. 3, 4

• Simplification strategies to consider at future visits:
  • Consolidate dosing frequencies where possible (e.g., aspirin to daily rather than EOD). 3
  • Evaluate whether all medications remain necessary (e.g., ferrous sulphate given normal ferritin of 134). 5
  • Consider combination products if appropriate to reduce pill burden. 3

Monitoring and Follow-Up Schedule

Schedule medication regimen review every 3-6 months as recommended for patients with type 2 diabetes. 1

• Monitor HbA1c every 3-6 months to assess glycemic control. 1
• Monitor renal function (eGFR) and electrolytes at least annually, or every 3-6 months given use of losartan and metformin. 1
• Monitor lipid panel annually given current excellent control. 1
• Blood pressure monitoring at each visit. 1

Common Pitfalls to Avoid

• Do not discontinue metformin when adding other agents; it should remain the foundation of therapy. 1
• Do not delay treatment intensification if HbA1c rises above target at future visits; recommendations for intensification should not be delayed. 1
• Avoid unnecessary medication changes during routine visits when control is adequate, as frequent changes can reduce adherence and increase complexity. 1, 6
• Do not overlook medication regimen complexity as a barrier to adherence; regularly assess whether simplification is possible. 3, 4