Case 6—A Newly Diagnosed Patient with a High BMI—is a very common scenario for the primary care physician. There are a number of issues worth highlighting before I outline my suggestions for treatment.

Initial Considerations

First, it is important to determine the severity of the various conditions being presented and prioritize accordingly. When a young patient presents with uncontrolled hypertension, dyslipidemia, and hyperglycemia, it is important to focus first on what treatment will help the patient to live the longest (insure the greatest life expectancy). While many physicians will focus on hyperglycemia first, I would argue that treating hypertension and dyslipidemia first has better mortality benefits and thus these two conditions should be the first to be treated. Early use of a statin and ACE inhibitor in this patient may also reduce the microvascular and macrovascular complications of diabetes. 

In light of the diagnoses, the patient is likely to be overwhelmed. Remind him that lifestyle changes can help all three problems and may reduce the number of medications he will need to take. I would also reinforce that his current activity, taking weekend bicycle rides, is some activity and a positive step toward wellness. Encourage him to maintain and build upon this activity.

With a new diagnosis of hypertension, dyslipidemia, and diabetes, it is important to schedule a follow-up visit as early as 1-2 weeks from the initial visit in order to reinforce important behavior changes and offer encouragement to help him adjust to these new medical problems. In addition to scheduling the follow-up visit, the patient should be referred for diabetes education. The patient should be encouraged to adopt a healthy diet.  Most people do not recognize that a well thought out dietary plan for diabetes can help all of this patient’s newly diagnosed problems.

One final note about the patient’s initial presentation: this patient presented with what sounded like polydipsia and weight loss. When a patient presents with the “polys”—polyuria, polydipsia, and polyphagia—and weight loss, the physician should look for decompensated diabetes and start treatment with insulin immediately. This is necessary to reduce “glucotoxicity” and “lipotoxicity.”

Reinforcing Successful Behaviors at Follow-up

At 3 months the patient returns with better blood pressure and lipid control. This is already a success, as few patients have these conditions controlled at 3 months. This is a great time to reinforce the patient’s contribution to his progress. Since he is someone who has chronically struggled with behavior change, I would really focus on the success messages that could come from this. In just 3 months he has been able to lower his A1c with no medication for glucose control. I would also remind him that intermediate outcomes will likely improve before weight loss.

This follow-up visit is an opportunity to reinforce positive behavior change. If he was able to lose weight during the 3 months as well then he has really been successful. Most people will gain an average of 6 lbs per 1% that they lower their A1c, so even weight neutrality can be spun as a positive message with improved control. These small congratulatory statements can substantially improve patient adherence to treatment.

Treating the Hyperglycemia

Back to the current question: how do we treat a person with type 2 diabetes diagnosed 3 months ago who now has an A1c of 8.2%? All of the options listed in Case 6 are likely to help this patient. We have an opportunity to choose treatments for both glycemic and non-glycemic benefits.

I recommend again that you congratulate the patient on improvements made as a result of behavior change, and explore any barriers that may prevent him from maintaining his success. Since this is someone who went from no meds to three meds at the first visit, I think we need to be very sensitive to the notion that he may have a threshold in which adherence will worsen with too many medications. I want our first attempt at treatment to be effective and well-targeted (fasting versus post-meal hyperglycemia), to have little to no side effects, and to have non-glycemic benefits that he finds attractive.

With that in mind, I would choose a combination therapy as his initial glucose treatment. Since he is young and at very high risk but with no known complications or cardiovascular disease, I think we should shoot for an A1c of less than 6.5%. This means we will need either two agents or insulin to get him to goal. Choosing a combination of a DPP-4 inhibitor and metformin allows for efficacy, weight neutrality to possible weight loss, and a very low risk of hypoglycemia. Further, even though this combination is branded and may be more expensive, it may be more attractive as it is seen as only one additional medication.

Another option is the use of a GLP-1RA. This injectable therapy has many of the benefits we want, including weight loss, low risk of hypoglycemia, and a potential decrease in blood pressure, plus there is also a once weekly option that may improve adherence over the once daily formulation. While injectable treatments are barriers to some people, many will consider an injection with the promise of weight loss while improving glycemic control. One cautionary note: if we combine a GLP-1RA and metformin we may want to stagger the treatment initiation as both have gastrointestinal side effects. Starting them at the same time may be intolerable to many patients.

Combination therapy for this patient is the most likely to help him achieve glucose control quickly and limit side effects and burden of medications, while maximizing the non-glycemic benefits.

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