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Question #821

Mr. Hernandez is an overweight (BMI 30 kg/m2), 45-year-old plumber of Hispanic heritage who arrives at your office for a first-time visit. He has not been to a physician during the last 7 years because he hasn’t always had health insurance and “doesn’t like going to the doctor.” However, he has been noticing lately that his vision seems a little blurry and he’s developed a red, itchy rash in his groin. He is a non-smoker and recalls being told a long time ago that he should eat a low salt diet, but he can’t remember why. On examination, his BP is 154/96 mm/Hg, and his pulse is 72, RR 22. His physical exam is notable for signs of a yeast infection in his groin. You order a CBC, Chem 12 panel and A1C to be drawn that day before he leaves. You advise him how to treat his skin infection. When you receive the results of the Chem 12 panel, it shows a random plasma glucose of 162 mg/dL. His A1C was 7.3%. You call Mr. Hernandez and ask him to return the next morning, before he has eaten, for additional labs.

In this individual, you might order all the following labs EXCEPT urine ketones. Mr. Hernandez labs return and are notable for A1C 7.5, FPG 137 mg/dL, LDL-cholesterol 190 mg/dL, HDL-cholesterol 38 mg/dL and triglycerides 232 mg/dL. You discuss his lab results, his diagnosis and how to manage diabetes, and make referrals to the appropriate diabetes team clinicians. You start Mr. Hernandez on metformin, lifestyle modifications, an ACE inhibitor and a statin.

What glycemic and blood pressure parameters are you looking to achieve for most individuals?

 

Correct

Answer: D. A1C<7%, BP<140/90 mmHg

For most adults with diabetes, A1C<7%, has been associated with reduced microvascular complications, and if implemented soon after diagnosis, is associated with long-term reduction in macrovascular disease.

Managing blood pressure in most people with diabetes and hypertension should be treated to a systolic BP of <140 mmHg. Lower targets may be appropriate for certain individuals, if it can be achieved with undue treatment burden.

According to the ADA regarding systolic targets:

  • People with diabetes and hypertension should be treated to a systolic blood pressure goal of 140 mmHg.
  • Lower systolic targets, such as 130 mmHg, may be appropriate for certain individuals with diabetes, such as younger patients, those with albuminuria and/or those with hypertension and one or more additional atherosclerotic cardiovascular disease risk factors, if they can be achieved without undue treatment burden.

For diastolic targets:

  • Individuals with diabetes should be treated to a diastolic blood pressure goal of 90 mmHg.
  • Lower diastolic targets, such as 80 mmHg, may be appropriate for certain individuals with diabetes, such as younger patients, those with albuminuria, and/or those with hypertension and one or more additional atherosclerotic cardiovascular disease risk factors, if they can be achieved without undue treatment burden.

References:

American Diabetes Association. Glycemic targets. Diabetes 2016. Diabetes Care 2016;39(Suppl. 1): S39-S46

American Diabetes Association. Cardiovascular disease and risk management. Sec. 8. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1): S60–S71

Incorrect