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Weight and T2D: Case 1

CE / CME

Shifting the Treatment Paradigm of Weight Management and Type 2 Diabetes in Primary Care: Interactive Case Challenge 1

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Nurses: 1.00 Nursing contact hour

Physicians: Maximum of 1.00 AMA PRA Category 1 Credit™

ABIM MOC: maximum of 1.00 Medical Knowledge MOC point

Released: October 31, 2023

Expiration: October 30, 2024

Martin J Abrahamson
Martin J Abrahamson, MD, FACP
Debbie Hinnen
Debbie Hinnen, APN, BC-ADM, CDCES, FAAN
CME/CE Information

Activity

Progress
1
Course Completed

History 
A 57-year-old man presents for primary care follow-up after a recent urgent care visit due to polyuria approximately 1 month ago. In urgent care, he was found to have a blood glucose of 287 mg/dL and an A1C of 9.5%. His ketones were negative, aspartate aminotransferase was 15 U/L, alanine aminotransferase was 40 U/L, and blood pressure was 128/72 mm Hg. At that encounter, he was started on metformin 500 mg twice daily and insulin glargine 10 units at bedtime and instructed to follow up with his primary care provider. Prior to this incident, his medical history included prediabetes, obesity (BMI 32 kg/m2), osteoarthritis, and hypertension, and medications included lisinopril 20 mg daily and acetaminophen 500 mg twice daily. 

Current Presentation 
The patient provides a fasting blood glucose log showing an average blood glucose of 190 mg/dL. He reports tolerating metformin well and states that he is willing to take an injectable medication, but he frequently forgets to inject his nightly insulin. He denies symptoms of hypoglycemia and states that he is interested in the medications he has seen on TV that help with diabetes and weight loss, as he has been trying to lose weight with lifestyle changes including eliminating simple sugars and starting walking 3-4 times weekly since his T2D diagnosis but has not been successful. His current vitals are blood pressure 127/70 mm Hg, pulse 72 beats/min, height 5 ft 10 in, weight 223 lb, waist circumference 40 in. Recent labs show a urine albumin–creatinine ratio of 20 mg/g and an estimated glomerular filtration rate of 85 mL/min/1.73 m2. Total cholesterol is 240 mg/dL, low-density lipoprotein cholesterol is 136 mg/dL, high-density lipoprotein cholesterol is 40 mg/dL, and triglycerides are 250 mg/dL. All other labs are within normal limits. 
You determine this patient’s A1C goal to be less than 7.0%. You decide to increase metformin to 1000 mg twice daily because the patient is tolerating it well and refer the patient to a diabetes educator for additional counseling on lifestyle changes, including diet and exercise. You also start atorvastatin 40 mg daily to lower his cholesterol. 

Question 1

Which of the following additional interventions would be best for this patient at this time to improve blood glucose control and assist with weight management?