What is the best management plan for a 57-year-old patient with Type 2 Diabetes Mellitus (T2DM), obesity, and bilateral shoulder pain, who is currently on NovoMix (Insulin Aspart) and Jardiamet (Empagliflozin and Metformin), and experiencing headaches and limited mobility in the left shoulder?

Management of T2DM with Bilateral Shoulder Pain in a 57-Year-Old Patient

This patient requires optimization of diabetes management with addition of an SGLT2 inhibitor to current therapy, conservative management of left shoulder impingement syndrome with NSAIDs and physical therapy, and consideration of work modification given the physical demands of seasonal strawberry work. 1, 2

Diabetes Management Optimization

Current Glycemic Control Assessment

• The patient's most recent HbA1c values show suboptimal control (specific values redacted but trending pattern suggests need for intensification) 3
• Current regimen of NovoMix (premixed insulin aspart) 30 units twice daily plus Jardiamet (empagliflozin 12.5mg/metformin 1000mg) twice daily requires optimization 3, 1

Recommended Medication Adjustments

Add empagliflozin 25mg (or increase current SGLT2 inhibitor dose if on lower dose) to maximize cardiovascular and renal protection, given this patient's obesity and diabetes duration >10 years. 1, 4, 5

• The combination of metformin plus SGLT2 inhibitor is first-line therapy for T2DM patients with comorbidities like obesity 1
• Empagliflozin specifically reduces HbA1c by 0.5-1.0%, body weight by 1.5-3.5 kg, and systolic blood pressure by 3-5 mmHg 6, 4
• In patients on insulin therapy, empagliflozin addition reduces insulin requirements by 9-11 units/day while improving glycemic control without increasing hypoglycemia risk 7
• The EMPA-REG OUTCOME trial demonstrated 38% reduction in cardiovascular mortality and 32% reduction in all-cause mortality in patients with T2DM 4, 5

Insulin Regimen Optimization

Continue NovoMix but titrate dose based on self-monitoring blood glucose every 2-4 hours, with adjustments every 3-6 months to avoid overbasalization. 3

• Monitor for signs of overbasalization: basal dose >0.5 units/kg/day, high bedtime-morning glucose differential, hypoglycemia, or high glycemic variability 3
• If HbA1c remains above target after 3 months, consider switching from premixed insulin to basal-bolus regimen (basal insulin plus rapid-acting insulin at meals) for better postprandial glucose control 3

Metformin Continuation

Continue metformin at current dose (1000mg twice daily) as it provides cardiovascular benefits and mortality reduction. 3, 1

• Monitor vitamin B12 levels periodically given long-term metformin use (>10 years) and presence of minimal retinopathy/maculopathy 3
• Ensure renal function monitoring given albumin-creatinine ratio <30 mg/g (normal) but need ongoing surveillance 3

Shoulder Pain Management

Left Shoulder Impingement Syndrome Treatment

Initiate conservative management with NSAIDs, physical therapy focusing on rotator cuff strengthening and scapular stabilization, and activity modification. 2

• Clinical examination findings (positive impingement signs, reduced external rotation, pain on passive/active movements, limited internal rotation against resistance) are consistent with subacromial impingement syndrome 2
• Prescribe NSAIDs (e.g., naproxen 500mg twice daily or ibuprofen 600mg three times daily) for 2-4 weeks for pain control 2
• Refer to physical therapy for supervised therapeutic exercises focusing on rotator cuff strengthening, scapular stabilization, and range of motion restoration 2
• Avoid overhead activities and repetitive reaching during strawberry picking work 2

Bilateral Shoulder Considerations

The right shoulder requires monitoring but may benefit from preventive exercises given bilateral involvement pattern. 2

• Morning stiffness and sleep disturbance suggest inflammatory component requiring NSAIDs 2
• Bilateral involvement in context of T2DM raises consideration of adhesive capsulitis (frozen shoulder), though examination findings favor impingement 2

Work Capacity and Medical Certificate

Work Modification Recommendations

Provide medical certificate recommending modified duties avoiding overhead work and repetitive reaching for 6-8 weeks while undergoing conservative shoulder treatment. 2

• Current seasonal strawberry work involves repetitive overhead reaching and bending that exacerbates shoulder impingement 2
• Patient's stated desire to stop work due to headaches and shoulder pain is medically justified given examination findings 2
• Document functional limitations: unable to lift left arm above head, pain radiating to elbow, affecting sleep and daily activities 2

Headache Management

Evaluate headache pattern and consider tension-type headaches related to neck/shoulder muscle tension versus other causes.

• Headaches in context of bilateral shoulder pain and physical work suggest musculoskeletal origin
• If headaches persist after shoulder treatment initiation, consider further evaluation for other causes
• NSAIDs prescribed for shoulder pain will also address tension-type headaches

Diabetes Complication Screening and Prevention

Retinopathy Monitoring

Continue annual comprehensive eye examinations given minimal retinopathy and mild maculopathy findings. 3

• Current findings (minimal retinopathy, mild maculopathy left eye) require ongoing surveillance 3
• Optimizing glycemic control, blood pressure, and lipid control is key to slowing progression 3

Nephropathy Surveillance

Monitor albumin-creatinine ratio and eGFR every 3-6 months given T2DM duration >10 years. 3, 1

• Current albumin-creatinine ratio <30 mg/g is normal but requires ongoing monitoring 3
• If albumin-creatinine ratio increases to >30 mg/g on two of three specimens over 3-6 months, consider ACE inhibitor or ARB initiation 3

Neuropathy Assessment

Perform annual foot examination with 10-g monofilament testing plus assessment of vibration, pinprick sensation, and ankle reflexes. 3

• Patient's left arm pain radiating to elbow warrants evaluation for cervical radiculopathy versus peripheral neuropathy
• Diabetic peripheral neuropathy can be treated with pregabalin, duloxetine, or gabapentin if present 3

Cardiovascular Risk Management

Lipid Management

Check fasting lipid panel and consider statin initiation given T2DM, age 57, and obesity. 3

• Total cholesterol value provided but need complete lipid panel for risk stratification 3
• In adults 40-75 years with diabetes, moderate-intensity statin therapy is indicated regardless of 10-year ASCVD risk 3
• Consider high-intensity statin if multiple ASCVD risk factors present (obesity, diabetes duration >10 years, hypertension if present) 3

Blood Pressure Monitoring

Assess blood pressure at each visit and optimize control to <130/80 mmHg. 3

• SGLT2 inhibitors provide additional blood pressure reduction benefit (3-5 mmHg systolic) 6, 4

Weight Management Strategy

Lifestyle Interventions

Implement structured dietary counseling focusing on calorie restriction (500-750 kcal/day deficit) and heart-healthy dietary pattern. 3

• Current BMI 34.8 kg/m² (obesity class I) requires weight loss intervention 3
• Target weight loss of 5-10% body weight (approximately 5-10 kg) over 6 months to improve glycemic control and ASCVD risk factors 3
• Emphasize whole grains, vegetables, lean proteins, and avoidance of highly energy-dense foods 3

Physical Activity Prescription

Prescribe 150 minutes per week of moderate-intensity physical activity once shoulder pain improves, starting with low-impact activities. 3

• Begin with walking, stationary cycling, or water-based exercises that avoid shoulder stress 3
• Add resistance training 2-3 sessions per week after shoulder rehabilitation progresses 3
• Physical activity provides additional benefits including enhanced body fat loss, preservation of fat-free mass, and reduction in cardiometabolic risk factors 3

Follow-Up Schedule and Monitoring

Short-Term Follow-Up (2-4 Weeks)

Reassess shoulder pain response to NSAIDs and physical therapy, evaluate headache resolution, and review blood glucose patterns. 3, 2

• Adjust insulin doses based on self-monitoring blood glucose logs 3
• If shoulder pain not improving, consider corticosteroid injection or imaging (ultrasound or MRI) 2

Medium-Term Follow-Up (3 Months)

Check HbA1c, assess medication adherence, evaluate weight loss progress, and review physical therapy outcomes. 3, 1

• Target HbA1c reduction of 0.5-1.0% with medication optimization 3
• If HbA1c remains >7% (53 mmol/mol), intensify insulin regimen or consider GLP-1 receptor agonist addition 3
• Reassess work capacity and update medical certificate as needed 2

Long-Term Monitoring (Every 3-6 Months)

Perform comprehensive diabetes assessment including HbA1c, lipid panel, albumin-creatinine ratio, eGFR, vitamin B12, and annual retinal screening. 3, 1

• Monitor for SGLT2 inhibitor adverse effects: genital mycotic infections, volume depletion, and rare ketoacidosis 3, 1
• Assess for signs of insulin overbasalization and adjust regimen accordingly 3

Critical Safety Considerations

SGLT2 Inhibitor Sick Day Rules

Educate patient to temporarily stop empagliflozin during acute illness with dehydration, vomiting, or diarrhea. 3, 1

• Risk of diabetic ketoacidosis and volume depletion increases during illness 3
• Resume SGLT2 inhibitor within 24-48 hours of eating and drinking normally 1
• Check ketones if symptoms of ketoacidosis develop (nausea, vomiting, abdominal pain, fatigue) 1

Hypoglycemia Prevention

Educate patient on hypoglycemia recognition and treatment, particularly given insulin use. 3

• Risk of hypoglycemia increases with insulin therapy but not with SGLT2 inhibitor or metformin alone 3
• Provide glucose tablets and glucagon emergency kit 3
• Instruct on self-monitoring blood glucose before meals and bedtime 3