Test Your Knowledge #533: A Woman with Hypertension, Obesity and Type 2 Diabetes Characterized by Prominent Postprandial Hyperglycemia Objective, Part Two of Three
Mrs. Robinson is a 55-year-old African-American woman who presents for a routine follow-up visit.
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She is married and the mother of 3 grown children.
She stopped working as a waitress 6 months ago to care for her infant grandson.
Type 2 diabetes mellitus was diagnosed 5 years ago; hypertension 12 years ago.
She has been overweight all of her adult life, and has gained 20 pounds since quitting work.
Mrs. Robinson feels her diet hasn't changed much since she decided to stay home with her grandson, although she admits to doing more snacking and states she loves juice and drinks it with all her meals. Her job as a waitress was very active, and she knows her activity level has decreased significantly since she quit. While at her waitressing job, she experienced chronic knee pain caused by osteoarthritis; she expected this to improve once she quit working, but instead it has worsened with her weight gain and decreased activity.
Because she has been concerned about her increasing blood glucose levels, in advance of her appointment Mrs. Robinson faithfully monitored her pre-meal blood glucose levels 3 times daily, 3 days a week. She occasionally measured her blood sugar 2 hours after eating as well. She states that she does not want to go on any medications that will make her gain more weight.
Case Details
Physical exam / review of systems
Laboratory values
Overweight female in no acute distress
A1c 8.6%
Height 67 inches
Fasting blood glucose 108-142 mg/dL
Weight 234 lbs
Postprandial blood glucose (2 hours after meals) usually >250 mg/dL
Most recent eye exam 4 months ago, normal exam with no retinopathy
Estimated GFR 46.6 mL/min
Urine microalbumin 180 mg/24 hours
Current medications
Glimepiride 4 mg daily
Enalapril 10 mg daily
Amlodipine 10 mg daily
Pravastatin 20 mg daily
Acetaminophen 650 mg twice daily
GFR ranges and stages of kidney disease
Mrs. Robinson’s GFR
GFR Range (mL/min/1.73 m2)
Clinical Features
At risk
>60
Diabetes, hypertension, family history
Stage 1
>90
Microalbuminuria: diabetes 5-10 years, retinopathy, rising blood pressure
Stage 2
60-89
Albuminuria: diabetes 10-15 years, retinopathy, hypertension
Stage 3
46.6
30-59
Hypertension, retinopathy, CVD, other diabetes complications
Stage 4
15-29
Stage 5
<15
Retinopathy, CVD, other diabetes complications, uremia
Source: National Kidney Foundation
GFR = Glomerular filtration rate; CVD = Cardiovascular disease
Lipid levels for women with Type 2 diabetes
Mrs. Robinson
ADA / ACC / AHA Recommendations
LDL
96 mg/dL
<100 mg/dL
HDL
44 mg/dL
>50 mg/dL
Triglycerides
145 mg/dL
<150 mg/dL
ADA = American Diabetes Association ACC = American College of Cardiology AHA = American Heart Association
Based on Mrs. Robinson's initial presentation and laboratory values, what pharmacologic therapy would you recommend to treat her hyperglycemia and hypertension?
Increase enalapril to 20 mg twice daily and add pioglitazone 30 mg daily.
Continue enalapril and amlodipine; stop glimepiride and start metformin 500 mg twice daily and basal insulin.
Increase enalapril to 20 mg twice daily and continue amlodipine; continue glimepiride and add exenatide 5 g twice daily.
Continue enalapril, amlodipine, and glimepiride; add metoprolol 50 mg and sitagliptin 100 mg.
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