A 38-year-old Caucasian male presents to your office reporting symptoms of fatigue, thirst, and weight loss. He has not been to a physician since his late 20s. Your physical examination shows high blood pressure (150/96 mmHg) and a BMI (body-mass index) of 36 kg/m2. There is a family history of cardiovascular disease, although the patient himself reports having no personal history of cardiac symptoms or cardiovascular events.
The blood test you order shows his HbA1c level to be 8.6%, as well as hypercholesterolemia (LDL=130 mg/dL) and hypertriglyceridemia (triglycerides=350 mg/dL). All other cardiorespiratory, abdominal, and neurologic findings are normal. You diagnose him with type 2 diabetes, hyperlipidemia, hypertension, and obesity.
The patient reports struggling with his weight since childhood and trying numerous diets over the years with varying but always temporary success. You calculate that his BMI has fluctuated between 34 and 36 kg/m2 for most of his adult life. His job as an accountant is largely sedentary, and between demands of work and his young family, he has not been able to fit regular exercise into his life other than weekend bike rides.
The patient has health insurance through his employer, including prescription drug coverage. You counsel him about lifestyle changes to address his newly diagnosed diabetes and over the next 8 weeks sequentially prescribe hydrochlorothiazide (25 mg daily) and lisinopril (20 mg daily) for the hypertension, and atorvastatin (20 mg daily) for the hyperlipidemia. You examine him again in 3 months to find that his blood pressure and lipid levels fall within normal ranges, but his HbA1C is 8.2%. You now must decide how to manage the T2DM.
Which one of the following treatment options do you think would be most appropriate for this patient?
1. Monotherapy with Metformin
2. Initial Combination Therapy
3. Bariatric Surgery