What are the next management steps for a 60‑year‑old man with hypertension (blood pressure 150/80 mm Hg on losartan and amlodipine), type 2 diabetes on metformin, asthma on budesonide/formoterol (Symbicort), albuterol/ipratropium, albuterol tablets, levocetirizine/montelukast, and budesonide, a 40‑pack‑year smoking history, frequent alcohol use, mild normocytic anemia, elevated low‑density lipoprotein cholesterol, non‑HDL cholesterol, and triglycerides, and early peripheral neuropathy (impaired vibration sense with negative 10‑g monofilament)?

Management of 60-Year-Old Man with Uncontrolled Hypertension, Diabetes, Dyslipidemia, and Early Peripheral Neuropathy

This patient requires immediate intensification of his antihypertensive regimen with addition of a statin for cardiovascular risk reduction, initiation of pharmacologic therapy for neuropathic pain, aggressive foot care education, smoking cessation counseling, and alcohol reduction.

Blood Pressure Management

Add a thiazide diuretic (chlorthalidone 12.5-25 mg daily) to his current losartan 100 mg and amlodipine 10 mg regimen immediately. His blood pressure of 150/80 mmHg remains above the target of <130/80 mmHg for diabetic patients despite maximum doses of two agents 1.

• The American Diabetes Association guidelines specify that diabetic patients should achieve systolic BP <130 mmHg and diastolic BP <80 mmHg 1
• His current regimen of losartan (an ARB) plus amlodipine (a calcium channel blocker) represents appropriate first-line combination therapy, but the doses are already maximized 2
• Adding a thiazide diuretic as the third agent is the evidence-based next step, with chlorthalidone preferred over hydrochlorothiazide for superior cardiovascular outcomes 2
• The LIFE study demonstrated that losartan-based therapy (often requiring addition of hydrochlorothiazide) effectively reduces cardiovascular events in hypertensive diabetic patients 3
• Most diabetic patients with hypertension require three or more medications to achieve BP control 1

Lipid Management

Initiate high-intensity statin therapy with atorvastatin 40-80 mg daily immediately. His LDL cholesterol of 2.79 mmol/L (108 mg/dL) exceeds the target of <2.58 mmol/L (100 mg/dL), and his non-HDL cholesterol and triglycerides are also elevated 1.

• This patient has diabetes with multiple cardiovascular risk factors (hypertension, smoking, dyslipidemia, peripheral neuropathy), placing him at very high cardiovascular risk 1
• Statin therapy has proven mortality benefit in diabetic patients with dyslipidemia 1, 4
• His elevated triglycerides (1.84 mmol/L) and low HDL pattern are typical of diabetic dyslipidemia 4
• After achieving LDL goal with statin therapy, if triglycerides remain >1.70 mmol/L, consider adding fenofibrate 4

Peripheral Neuropathy Management

Initiate pregabalin 75 mg twice daily (150 mg/day total), titrating to 300-600 mg/day in divided doses as tolerated for neuropathic pain management 1, 5.

• His impaired vibration sense and delayed 10-g monofilament sensation indicate loss of protective sensation (LOPS) and established diabetic peripheral neuropathy 1
• Pregabalin is FDA-approved and recommended as first-line therapy for diabetic peripheral neuropathy 1, 5
• Alternative first-line options include duloxetine or gabapentin if pregabalin is not tolerated 1
• Optimize glycemic control aggressively as this is the only intervention proven to slow neuropathy progression, though it will not reverse existing neuronal loss 1

High-Risk Diabetic Foot Care

This patient is at extremely high risk for foot ulceration and amputation and requires immediate comprehensive foot care intervention 1.

• He has multiple high-risk features: peripheral neuropathy with LOPS, 40 pack-year smoking history, poor glycemic control (implied by neuropathy presence), and hypertension 1
• Provide intensive education on daily foot self-inspection, proper footwear, and immediate reporting of any skin breakdown 1
• Refer to podiatry for evaluation and consideration of custom-fitted therapeutic shoes 1
• Schedule foot examinations at every clinic visit, not just annually, given his high-risk status 1
• Assess pedal pulses and consider ankle-brachial index testing to screen for peripheral arterial disease, as he is >50 years old with multiple PAD risk factors (smoking, hypertension, dyslipidemia, diabetes) 1

Smoking Cessation

Initiate formal smoking cessation program immediately 1.

• His 40 pack-year smoking history dramatically increases his risk for cardiovascular events, peripheral arterial disease, and diabetic foot complications 1
• Smoking cessation is a critical intervention that impacts all his comorbidities 1
• Consider pharmacotherapy (varenicline, bupropion, or nicotine replacement) combined with behavioral counseling 1

Alcohol Reduction

Counsel on reducing alcohol intake from weekly frequent consumption to moderate levels (≤2 drinks/day for men) 1.

• Excessive alcohol consumption can worsen hypertension control and interfere with medication adherence 1
• Alcohol reduction may contribute to blood pressure lowering 1

Anemia Evaluation

Order iron studies, vitamin B12, and folate levels to evaluate his mild normocytic anemia (Hgb 124 g/L, normal 130-180) 6.

• While mild, anemia in diabetic patients with chronic kidney disease (though his eGFR is currently normal) warrants investigation 6
• His metformin use raises consideration of B12 deficiency 6
• Anemia can worsen cardiovascular outcomes and quality of life 6

Retinopathy Screening

Refer for comprehensive dilated eye examination by ophthalmologist or optometrist if not done within the past year 1.

• All patients with type 2 diabetes should have annual comprehensive eye examinations 1
• Given his established microvascular complications (neuropathy), retinopathy screening is particularly important 1
• Optimizing blood pressure and lipid control reduces retinopathy progression risk 1

Nephropathy Screening

Order spot urine albumin-to-creatinine ratio to screen for diabetic nephropathy 1.

• All diabetic patients with hypertension should be screened for albuminuria 1
• His current ACE inhibitor/ARB therapy (losartan) is appropriate for nephroprotection if albuminuria is present 1
• Two of three specimens over 3-6 months should be abnormal (>30 mg/g) to confirm albuminuria 1

Follow-Up Schedule

• Recheck blood pressure in 2-4 weeks after adding thiazide diuretic to assess response and tolerability 1, 2
• Monitor serum potassium and creatinine 1-2 weeks after adding diuretic, given concurrent losartan use 1
• Reassess neuropathic symptoms in 2-4 weeks after initiating pregabalin and titrate dose as needed 1, 5
• Recheck lipid panel in 6-12 weeks after statin initiation 1
• Schedule comprehensive foot examination at every visit 1