Test Your Knowledge #525: A Woman with Type 2 Diabetes and Hyperlipidemia, Part Three of Three

• She is married and the mother of 4.
• She stopped smoking 3 years ago when trying to conceive and gained a significant amount of weight.
• Both parents have Type 2 diabetes.
• She was diagnosed with Type 2 diabetes mellitus 2 years ago after delivering an infant that was large for gestational age.

When first diagnosed, she met with a dietitian for medical nutrition therapy.  She found this helpful -- after making diet changes and walking regularly with her children, she was able to lose 18 pounds in 6 months.  Her A1c at that time was 6.8% without antidiabetic medication.

Mrs. Carmend reports it has been more difficult to continue her nutrition regimen since returning to her full-time job 18 months ago as a receptionist in a business office. She often eats at a restaurant for lunch and then orders out or prepares convenience foods for dinner; finding time for regular exercise is also difficult. Since returning to work, she has gained 20 pounds. She self-monitors her fasting blood glucose levels occasionally, usually in the morning.

Although Mrs. Carmend does not want more children, she has not been using a reliable method of birth control. She believes that it took so long to get pregnant with her last child 3 years ago, she is not likely to get pregnant again now that she is over 40.

Mrs. Carmend’s physician discussed how her weight gain, poor glycemic control, and dyslipidemia put her at increased risk for cardiovascular disease and microvascular complications such as retinopathy, neuropathy, and nephropathy.  She expressed motivation to make changes to her diet and agreed to a series of follow-up visits with the dietitian that she saw after her initial diagnosis.  She also stated she would try to bring her lunch to work and take a walk during her lunch hour.

Her physician made the following treatment changes and recommendations:

• The metformin dose was increased to 1000 mg twice daily.
• The lovastatin 10 mg was changed to simvastatin 20 mg.
• She agreed to start an oral birth control medication.
• A follow-up blood pressure check was scheduled in 1 week, due to her mildly elevated blood pressure at this visit and the initiation of birth control medication.
• An ophthalmology exam was recommended as it has been more than a year since her previous exam.

Finally, Mrs. Carmend agreed to increase self-monitoring of her blood glucose to daily checks pre-breakfast as well as twice weekly 2-hour postprandial readings, alternating between after lunch or after dinner. 

Mrs. Carmend’s blood pressure one week after the visit was 132/82 mmHg.  As both the systolic and the diastolic readings were still above ADA recommendations (<130 mmHg and <80 mmHg, respectively) but the blood pressure did not increase, medication to reduce blood pressure was not started in the hope that continuation of her lifestyle changes may further improve her blood pressure. 

She has not experienced any side effects from the new oral birth control medication. 

Mrs. Carmend returned to the clinic 6 weeks after her initial visit.  In the meantime, she had completed a visit with her ophthalmologist and also had a fasting lipid profile drawn the day before her clinic visit. 

She reported consulting with the dietitian, making changes to lunches at work, and increasing her activity level by walking 30 minutes about 5 days a week.  She admitted having difficulty preparing healthy evening meals due to the food preferences of her family and a lack of time.

Question 3

Based on Mrs. Carmend’s presentation and laboratory values at the 6-week follow-up visit, what medication changes would you recommend?  (Please select the most appropriate response.)

B. Add a medication to further improve her glycemic control and hypertension, and reevaluate her lipid parameters in 6 weeks. 

C. Add a medication to further improve her lipid parameters, and reevaluate her glycemic control and hypertension in 6 weeks. 

D. Continue on the same medication regimen and reevaluate in 6 weeks.

For the correct answer, please click here.