Type II Diabetes
Jeremy Newsome. age 49
Name: Jeremy Newsome
Age: 49
Past Medical History:
Essential Hypertension
Type II Diabetes
Medication History:
Metformin 500mg TDS
Ramipril 2.5mg OD
Sitagliptin 100mg OD
Medical Notes:
Three weeks ago:
Seen by Giles Kennedy (Health Care Assistant): 16:59 pm
Diabetic Review:
Height: 178cm
Weight: 105kg
BMI: 33.2
Pulse: 83 regular
Blood Pressure: 148/89
Bloods taken today.
Investigation Results:
FBC: Normal
U+E: Normal
LFT's: Normal
Hba1c: 89
Notes: Hba1c on the rise, needs an appointment with a GP
Presenting complaint:
“I’ve been told that you wanted to see me, I’m guessing it’s about my blood tests.”
Open History: You already know about your results, as you’ve already asked reception. You’re aware that your blood sugars are getting higher and higher. You feel well in yourself. Your vision is fine. Whilst you are aware that higher blood sugars are not what the doctor wants, you feel well in yourself, and are not thirsty, don't have polyuria, and are not feeling tired. Your diet is poor, but only because your job doesn't lend itself very well to a regular diet. Easy access to drive through's and motorway services don't help your eating habits.
History if asked: Your compliance with medication is very poor. You often forget to take your medication, especially the Metformin. Not only is it difficult to take with food 3 times per day. You also don't remember to take your Rampril and sitagliptin that often, as you're out the door early most days, and find it difficult enough to remember to have a breakfast, let alone take your morning pills. You find that you're just so busy, that the tablets are just not a priority for you right now.
Social history: You work as a long distance lorry driver, and have done for 25 years. Eating healthy and regular meals is always difficult due to the varied nature of you work. Your work always starts very early, and you have difficulty remembering to take the tablets before you leave for work.
You don't smoke and you hardly drink any alcohol. You're working a lot of extra shifts at the moment, as your oldest child is struggling. He is in Jail for the second time, at the moment; for stealing. He will be out in 6 months. You know that he is a good person deep down, but that he struggles with finding work. This often leads him being unemployed and he then spends time with the wrong people. You want to try to break this pattern for him, and are saving up to help him start his own business when he is out. You're hope is that this will get him financially stable, and prevent him from going back to Jail. Working less is not an option for you at this moment in time.
Family History: You are the youngest of two brothers. You Both suffer from diabetes. Your Dad did also, although he passed away from a heart attack at the age of 60, and you're hoping the same doesn't happen to you. You have son and a daughter.
Past Medical History: You have Diabetes and high blood pressure
Ideas & Concerns: You genuinely feel you're doing the best you can, but your work makes taking all these tablets, especially taking tablets in the morning difficult. You know the potential risk with the diabetes, and would prefer to get the sugars down if possible.
Expectations: Your expectations are that the Doctor will likely give you another tablet, as long as this tablet doesn't give you issues with your HGV license (see below)
How To React: You will happily go along with whatever the doctor advises. However if the doctor wants to give you another tablet, you will be happy to take it as long as it doesn't cause a problem with your driving. You know that some diabetes medications can cause problems, so you don't want anything that will give you "hypo's". You also know that insulin will interfere with your ability to hold a HGV license, so you definitely don't want this.
Data Gathering & Diagnosis
Positive Indicators
Data gathering was gathered systematically and in an organised way
Data gathering was complete or sufficiently targeted to ensure patient safety (past medical history, allergies, Compliance with medication)
Effective use of existing information to assist in a safe assessment (Blood results, Blood pressure figures, height and weight data)
Relevant red flags were considered (allergies)
Psychological or social information to place the problem in context was completely identified
The implications of abnormal findings or results were fully recognised and understood
Adopts a structured and informed approach to problem-solving
Asks about alcohol intake, smoking history and other Social History
Discovers the psychosocial impact of the presenting complaint.
Negative Indicators
Makes immediate assumptions about the problem
Is disorganised/unsystematic in gathering information
Unable to interpret examination or investigations results
Fails to ask about Red Flags for the presenting complaint
Fails to ask about social or past medical history
Fails to ask about the impact of the condition on work
Clinical Management & Medical Complexity
Positive Indicators
Demonstrates the ability to formulate safe and appropriate management options which includes effective prioritisation, continuity and time and self-management.
The management plan was reflective of current best practice
A management plan that is complete
The prescribing of medications was reflective of current guidelines and best practice (see below for guidance)
Appropriate resources selected, including aspects of budgetary governance
Adequate arrangements for safe and sensible follow-up, continuity, and safety netting
Management options were responsive to the circumstances and preferences of those involved
Management options were prioritised in regard to perceived risk
Health improvement, rehabilitation, prevention, and health promotion were present or sufficiently encouraged
Negative Indicators
Does not suggest how the problem might develop or resolve
Fails to make the patient aware of the relative risks of different approaches
Follow-up arrangements are absent or disjointed
Fails to take account of related issues or co-morbidity
Does not discuss impact of current condition on work, and suggest options to help.
Health improvement or rehabilitation and health promotion were not considered.
Relating to Others
Positive Indicators
Appropriate or sufficient demonstration of respect/sensitivity during the consultation
Non-judgemental in approach
The patient’s autonomy and/or best interests were fully considered
Sufficient exploration of the patient’s agenda, health beliefs and/or preferences
Sufficient evidence of active listening and verbal and/or non-verbal communication skills
Explanations were sufficiently adapted to the patient’s context and level of understanding
The management plan was sufficiently shared for the patient to understand what they needed to do or the next course of action
Shows ability to communicate in a person-centred way.
Reaches shared understanding with patient
The impact of the problem on the patient was fully recognised
Effective negotiation concerning health behaviours
Adequate ownership of any decisions made
Negative Indicators
Doesn't enquire about patients’ Ideas, concerns and expectations
Takes a doctor centered approach toward management
Uses an explanation that is filled with jargon, or forgets to explain at all
Doesn't show any sympathy / empathy towards the patient's situation
Fails to empower the patient
Fails to recognise the impact of the problem on the patient.
Fails to demonstrate ethical awareness or recognise how cultural or personal differences may affect the consultation
Comes across as Judgmental during the consultation
Key Issues
Candidates knowledge of diabetes management
To remember about medication compliance prior to uptitrating or changing medication
Be aware of the medical implications of diabetes medication on driving HGV (click this link)
Explanation
"Taking your medication exactly as prescribed is really important for your health. Think of your medication like a key that unlocks your body's ability to fight illness or manage symptoms. If you skip doses or don't take it as directed, it's like having a key but not using it to open the door. Your health might not improve, and in some cases, it could even get worse. Sticking to your medication schedule helps make sure that the medicine works properly. It keeps the levels of medication in your body constant, which is crucial for it to be effective. Also, it helps prevent any unnecessary complications or side effects.
I understand that remembering to take your medication can be challenging, but it's vital to keep taking it as prescribed, even if you feel better, to ensure your health continues to improve or remains stable. Think of it as part of your daily routine, like eating meals or brushing your teeth."
Diabetes Management:
This is an interesting case, as they aren’t testing your knowledge of the fourth step in diabetes management, but rather your holistic approach to managing chronic conditions.
As you may be aware, the management of Diabetes has recently been updated with a new NICE Guidance on the matter: https://www.nice.org.uk/guidance/ng28
The first thing we need to establish is where their Hba1c Target should sit. The current recommendations from NICE are below:
Educate the person about their individual recommended HbA1c target, and encourage measures to achieve and maintain it, where possible.
Lifestyle including diet management — 48 mmol/mol (6.5%).
Lifestyle including diet combined with a single drug not associated with hypoglycaemia (such as metformin) — 48 mmol/mol (6.5%).
Drug treatment associated with hypoglycaemia (such as sulfonylurea): 53 mmol/mol (7.0%).
However not everyone fits neatly into those categories, and NICE have a very handy patient decision aid available here, that allows you to go through with the patient so that you can both work out what would be best for the patient.
Once you have an established target, the next thing to discuss is lifestyle measures, in all diabetic reviews. Ask the patient what their current lifestyle and diet is, what they would like it to be, what is a realistic aim for them, and what barriers, if any, exist to stop them from achieving their goals.
In this case, the barrier is his work, and in some ways, the three times daily dosing of metformin.
So what could we do in this case to help his control: Well, it wouldn’t be a good idea to add in any more medication at this time. Any further medication added could potentially increase the risk of hypoglycaemic attacks. This is something he would want to avoid given his line of work. Therefore we could look at amending the medication to make it easier for him to take.
As he is already on Metformin 500mg TDS, we could swap this to 1g M/R BD. This would likely double the effective dose he is getting (as he states he wasn’t really taking the lunchtime dose), and it would be easier for him to take as it’s only twice daily. To help remind him, you could suggest setting up alarms within his phone, or there are special apps you can download to your smartphone to help remind you.
What if his compliance was perfect:
If his compliance was perfect, and there were no glaring obvious changes he could make to his lifestyle, then we would need to look at increasing his diabetic medication to bring his blood sugars down. NICE guidance currently suggests the following:
1st Line, is still Metformin, standard release. Slowly up titrated. Once Metformin has been established then assess the person's cardiovascular status and risk to determine whether they; have chronic heart failure, have established atherosclerotic cardiovascular disease, or are at high risk of developing cardiovascular disease. Based on this cardiovascular risk assessment for the person with type 2 diabetes:
If they have chronic heart failure or established atherosclerotic cardiovascular disease, offer an SGLT-2 inhibitor with proven cardiovascular benefit in addition to metformin.
If they are at high risk of developing cardiovascular disease, consider an SGLT-2 inhibitor with proven cardiovascular benefit in addition to metformin.
If They have none of the above, and their Qrisk is under 10%, then just Start with Metformin Alone
If first-line treatment is ineffective, consider one of the following second-line treatment options:
For people who can take metformin, consider dual therapy with:
Metformin plus a DPP-4 inhibitor, or
Metformin plus pioglitazone, or
Metformin plus a sulfonylurea.
Metformin plus an SGLT-2 inhibitor may be considered if a sulfonylurea is contraindicated or not tolerated, or the person is at significant risk of hypoglycaemia or its consequences.
For people in whom metformin is contraindicated or not tolerated, consider the following:
Offer an SGLT-2 inhibitor to people with chronic heart failure or established atherosclerotic cardiovascular disease, and consider offering an SGLT-2 inhibitor to people at high risk of developing cardiovascular disease.
For other people, consider one of the following as first-line treatment:
A dipeptidyl peptidase-4 inhibitor (DPP-4 inhibitor).
A sulfonylurea.
A sodium-glucose cotransporter-2 inhibitor (SGLT-2 inhibitor) — this may be considered instead of a DPP-4 inhibitor if a sulfonylurea or pioglitazone is not appropriate.
If second-line treatment is ineffective, consider one of the following third-line treatment options:
For people who can take metformin:
Triple therapy by adding a DPP-4 inhibitor, pioglitazone, a sulfonylurea, or an SGLT-2 inhibitor (canagliflozin or empagliflozin). Note: dapagliflozin is recommended only in combination with metformin and a sulfonylurea, not pioglitazone, and ertugliflozin only in combination with metformin and a DPP-4 inhibitor, if a sulfonylurea or pioglitazone is not appropriate.
What would be of relevance in this case (If his compliance was excellent), is the section about second-line treatment not being effective, and what to add in third line. Given that he is already on Metformin and a DPP-4, then the next step could either be an SGLT-2 or a Sulfonylurea, depending on his Qrisk and preferences. Undoubtedly the sulfonylurea would be better at bringing the blood sugars down, but would increase his risk of Hypos and may cause problems with his driving. Therefore in this instance, adding in an SGLT-2 would be the better option, especially as it’s likely his Qrisk is greater than 10%.
Further Reading:
Last Updated: February 2024