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62-Year-Old Male Diagnosed with Type 2 Diabetes in 2015

His current medications include Metformin 1000 mg BID and glipizide ER 10 mg BID

Symptoms include recent weight gain of 10 pounds in 3 months, nocturia and thirst.

His family history includes that her father was diagnosed with T2D when he was 45 and was on oral medication for several years before requiring insulin and developing ESRD. His father also had a heart attack and died at age 67.

He has a history of fatty liver disease and consumes alcohol daily.

His fasting lab results include:

A1C = 8.6
Glucose = 197
Urine microalbinuria/Cr ratio = 60 mg/g
eGFR = 56 mL/min/ m2
ALT = 59 IU/L
C-peptide = 4.3 ng/mL

No recent eye exam.
He does not monitor his glucose at home.

What tests, referrals and medications would you order next?

  • from Generation NP 1 month
    Noncompliant patient. Trying to get his buy in to adherence with diet, exercise and stopping alcohol will have more effect on his outcome than anything else. He needs an eye and foot exam. I would stop the sulfonaurea, start SGLT-2, and GLP-1. A very frank conversation about his future health is needed. Unfortunately, he needs more time and counseling than many of us are allowed for an appointment, but it could save his life. He needs 3 month follow up. I would also offer dietary counseling if he is willing.
  • 1 month
    Non Compliant with diet obese male Type 2 diabetic with progression of the disease but intact beta cell reserve , with fatty liver and alcohol use , Chronic renal disease and famiy h/o CAD Needs to be counselled for diet exercise and compliance for diabetes and needs the intervention to stop the alcohol both for diabetes and Fatty liver ,, Glipizide needs to be stopped, metfomrin continued and addition of the GLP-1 and SGLT-2 for diabetes and positive CV out comes given the risk factors for CAD , SGLT-2 will also help with the prevention of the progression of the renal disease and it is presumed that Pt is on Statin therapy and on ACE-Inhibitor/ARB , GLP-1 will help with Fatty liver disease as well
  • from Endocrinologist Nation 1 month
    this pt will benefit from SGLT-2i given his microalbuminuria and stage 3 CKD, he needs eye exam, ACEI or ARB and a consultation w/endocrinology
  • 1 month
    Add GLP-1 and Ace inhibitor
    Lipid panel ,ECG
    Eye exam
    Liver ultrasound
  • from Generation NP 1 month
    Would stop the glipizide and change to sglt 2 inhibitor . Be more effective and may assist in prevention of cv and kidney disease . Send to CDE for diabetes self management classes .
    Consider adding glp1 agonist if stops drinking . Need to be cautious due to excessive alcohol with risk of pancreatitis .
    Order further labs cmp, CBC lipids , start baby asa , statin , fibroscan ;
    Needs ekg , consider calcium coronary ct scan or stress test .
  • 1 month
    I agree with Richard Kondan. I would also recommend a GLP-1 semaglutide for his diabetes and also helps with obesity. I would refer to an endocrinologist, nephrologist, and opthalmologist.
  • 1 month
    Stop the Glipizide. Add a GLP-1 CV protection such as Ozempic and a SGLT-2 inhibitor such as Farxiga. Continue Metformin.
  • 1 month
    Nonpharmacologic - Alcohol cessation counseling, Lifestyle modifications (weight loss, diet)
    Pharmacologic - Stop glipizide. Add ACEI, statin, ASA. Consider GLP-1 vs initiate insulin
    Preventative - Retinal and Podiatry examination. RUQ ultrasound
  • 1 month
    Also repeat RUQ US and check alphafetoprotein level.Liver clinic consult to do Fibroscan.
    Ophthalmology and Podiatry consults too
  • 1 month
    Check Lipids,Stop Glipizide,Start GLP-I,Also Statin,ACEI,Baby ASA,
    Consider stress test,Nephrology consult,advise pt to cut back on alcohol intake.
    consider Nutrition consult to go over diet again esp if not done in past.
  • from Pharmacist Society 1 month
    Diabetic training and if possible a CBGM
    Spot urine for alb: creat ratio
    Eye exam and foot exam
    ACEI
    Start a statin--moderate intensity
    investiage possibility of a GLP-1 drug
  • from Pharmacist Society 1 month
    I would recommend A1C and possibly an Ace and follow up with Eye and foot Dr
  • 1 month
    Order CMP, GFR Hba1c
    Urine for microalbumin
    A glp 1 would be a great choice
  • 1 month
    Fasting lipids, diabetic education/diet, EKG with possible stress test, exercise program, dilated eye exam, addition of ACEI, 81mg ASA, probable statin, long acting insulin.
  • 1 month
    Would stop the glipizide as it causes weight gain and switch to a glp1 agonist as it promotes weight loss; needs diet and exercise review; add a statin and ace inhibitor for renal protection. Needs close follow up.
  • from Generation NP 1 month
    EKG/stress test
    Cholesterol panel
    Add Lantus/long acting insulin
    Add ACE inhibitor
    Daily ASA
    Eye exam
    Consider nephrology consult
  • 1 month
    I would recommend that he attend Diabetic Teaching classes and start a GLP-1. He should have a follow up A1C in 2-3 months. He should have a podiatry and ophthalmology exams.