What is the best course of treatment for a 57-year-old patient with bilateral shoulder pain, type 2 diabetes mellitus (T2DM), obesity, and a history of abdominal hysterectomy with bilateral salpingectomy, who is currently taking Novomix (insulin aspart) and Jardiamet (empagliflozin and metformin), and has impaired glucose control, with a recent diagnosis of minimal retinopathy and mild maculopathy in the left eye?

Treatment Approach for Bilateral Shoulder Pain with T2DM and Retinopathy

For this 57-year-old patient with left shoulder impingement syndrome, initiate a short course of NSAIDs (if no contraindications), refer to physiotherapy for supervised rotator cuff strengthening and range-of-motion exercises, and provide work modification recommendations while optimizing diabetes control to prevent retinopathy progression.

Immediate Shoulder Pain Management

Left Shoulder Impingement Syndrome

• The clinical presentation (positive impingement tests, limited ROM all directions, pain on passive elevation/lowering, painful internal rotation against resistance) indicates subacromial impingement syndrome requiring conservative management as first-line therapy 1
• Prescribe a 7-14 day course of oral NSAIDs (such as naproxen 500mg twice daily or ibuprofen 600mg three times daily) for pain control, monitoring closely for gastrointestinal side effects and renal function given T2DM 1
• Refer urgently to physiotherapy for a structured program including pendulum exercises, progressive rotator cuff strengthening (particularly supraspinatus and external rotators), scapular stabilization exercises, and manual therapy techniques 1
• Advise immediate cessation of overhead strawberry picking work and provide medical certificate stating inability to perform overhead activities for minimum 4-6 weeks 1

Right Shoulder Monitoring

• The right shoulder currently has full ROM without pain, but bilateral symptoms suggest risk of progression 1
• Educate on preventive exercises and proper ergonomics to avoid bilateral impingement 1

Diabetes Management Optimization

Current Glycemic Control Assessment

• The patient's HbA1c trajectory and current glucose monitoring (BGL values not fully specified but monitoring twice daily) requires immediate intensification given the presence of minimal retinopathy and mild maculopathy 2, 3
• Current regimen of Novomix (biphasic insulin aspart) and Jardiamet (empagliflozin 12.5mg/metformin 1000mg or 2.5mg/500mg - dose not specified) shows suboptimal control based on retinopathy presence 2

Treatment Intensification Strategy

Add a GLP-1 receptor agonist immediately to the current regimen for three critical reasons: enhanced glycemic control, significant weight loss benefit (addressing obesity), and proven reduction in cardiovascular risk 2, 3

• The combination of empagliflozin (SGLT2 inhibitor) plus GLP-1 receptor agonist provides complementary mechanisms: empagliflozin reduces glucose reabsorption and provides cardiovascular/renal protection, while GLP-1 agonists enhance insulin secretion, suppress glucagon, slow gastric emptying, and promote 10-15% weight loss 3, 4
• Continue empagliflozin/metformin (Jardiamet) as it provides proven cardiovascular and renal benefits in T2DM patients, with demonstrated HbA1c reductions of 0.6-0.8% when combined with metformin 4
• Adjust Novomix insulin doses based on home glucose monitoring, potentially reducing doses as GLP-1 therapy takes effect to minimize hypoglycemia risk 2

Target Glycemic Goals

• Target HbA1c of 7.0-7.5% given the patient's age (57 years), presence of microvascular complications (retinopathy/maculopathy), and obesity 2
• Measure HbA1c every 3 months until target achieved, then at least twice yearly 3
• Continue twice-daily home glucose monitoring, targeting fasting glucose 80-130 mg/dL and 2-hour postprandial <180 mg/dL 2

Retinopathy Management

Ophthalmology Follow-Up

• Schedule ophthalmology examination within 3-4 months given the recent finding of minimal retinopathy and mild maculopathy in the left eye 2
• The presence of any diabetic retinopathy mandates more frequent monitoring than annual screening 2
• Emphasize that optimal glycemic control (HbA1c <7.5%), blood pressure control, and lipid management are critical to prevent retinopathy progression 2

Systemic Risk Factor Control

• Initiate or optimize blood pressure control targeting <140/90 mmHg (or <130/80 mmHg if tolerated) to slow retinopathy progression 2
• Check lipid panel and consider statin therapy if not already prescribed, as lipid control reduces retinopathy progression risk 2
• The patient can continue aspirin if prescribed for cardiovascular indications without adverse effect on retinopathy risk 2

Weight Management and Lifestyle Modification

Structured Weight Loss Program

• Target minimum 5% body weight loss (more than 10% increases chance of diabetes remission given obesity) 3
• Refer to diabetes care and education specialist for medical nutrition therapy to develop personalized food plan based on current diet (fish/meat with rice, no sweetened drinks) 3
• The combination of GLP-1 receptor agonist plus empagliflozin will facilitate weight loss: empagliflozin provides 2.4-3.2% weight reduction, while high-efficacy GLP-1 agonists can provide 10-15% or more weight loss 3, 4

Physical Activity Prescription

• Prescribe 150 minutes weekly of moderate-intensity aerobic activity broken into 10-15 minute sessions, modified to avoid overhead shoulder movements during recovery phase 3
• Add 5-minute activity breaks every hour to reduce sedentary time 3
• Once shoulder symptoms improve (4-6 weeks), incorporate resistance training twice weekly focusing on lower body and core initially 3

Work Capacity and Certification

Medical Certificate Recommendations

• Provide medical certificate stating unfit for overhead work activities for 4-6 weeks due to left shoulder impingement syndrome 1
• Patient may be fit for modified duties involving no overhead reaching, lifting <5kg, and frequent position changes 1
• Reassess work capacity at 4-week physiotherapy follow-up 1

Monitoring Schedule and Follow-Up

Short-Term (2-4 Weeks)

• Physiotherapy assessment and initiation of supervised exercise program 1
• Review NSAID tolerance and pain control 1
• Assess home glucose monitoring logs and adjust insulin doses if needed 2

Medium-Term (3 Months)

• Measure HbA1c to assess response to treatment intensification 3
• Shoulder examination to assess ROM improvement and pain reduction 1
• Review weight loss progress and reinforce lifestyle modifications 3
• Blood pressure and lipid panel assessment 2

Long-Term (6-12 Months)

• Ophthalmology follow-up for retinopathy monitoring (3-4 months initially, then as directed by ophthalmologist) 2
• Continue HbA1c monitoring every 3-6 months once at goal 3
• Annual comprehensive diabetes complication screening including foot examination, renal function (eGFR, urine albumin-creatinine ratio), and neuropathy assessment 2

Critical Pitfalls to Avoid

• Do not delay treatment intensification - the presence of retinopathy indicates inadequate long-term glycemic control requiring immediate action 2, 3
• Do not use corticosteroid injections for shoulder pain given T2DM and suboptimal glycemic control, as steroids will significantly worsen hyperglycemia 1
• Do not reduce empagliflozin dose based on eGFR unless <45 mL/min/1.73m² (dose not specified but patient appears to have preserved renal function) 4
• Do not overlook the RUQ pain - while previous ultrasound showed hepatic steatosis without stones, persistent symptoms warrant repeat evaluation given SGLT2 inhibitor use and obesity 1
• Monitor for genital infections with empagliflozin continuation, though urinary tract infection risk is not increased 4, 5, 6