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A 52-year-old man presents for routine check-up. BMI is 31 kg/m². He has hypertension on amlodipine. Fasting plasma glucose is 148 mg/dL and a repeat fasting glucose is 142 mg/dL. HbA1c is 7.6%. Urine ACR is 45 mg/g. eGFR is 62 mL/min/1.73 m². He has no osmotic symptoms. His father had type 2 diabetes and an MI at 58.
Questions
a) Confirm the diagnosis and classify the type. What diagnostic criteria did you use? (2 marks)
- Diagnosis: diabetes mellitus (1) — fasting plasma glucose ≥126 mg/dL (7.0 mmol/L) on two occasions; supported by HbA1c ≥6.5% (48 mmol/mol) (0.5).
- Most likely type 2 diabetes given age, obesity, hypertension, family history, and lack of ketosis/autoimmune features (0.5).
b) List his cardiorenal risk issues and set initial non-insulin pharmacotherapy priorities with rationale. (4 marks)
- Risks: T2DM + hypertension + albuminuria (ACR 45) + family premature CAD + obesity → high ASCVD/CKD risk (1).
- Metformin first-line if tolerated (start 500 mg, titrate toward 1 g BD) — efficacy, weight neutral/loss modest, cost (1).
- SGLT2 inhibitor (e.g. dapagliflozin 10 mg) strongly favoured for albuminuria/CKD and HF/ASCVD prevention even at this eGFR if initiation criteria met (1).
- Optimise BP with ACE inhibitor or ARB because of albuminuria (not amlodipine alone as the renal-protective strategy) (0.5).
- Statin for risk reduction; lifestyle (weight, diet, activity, smoking) (0.5).
c) What glycaemic target would you set, and which complications screening is due at diagnosis? (2 marks)
- Typical HbA1c target around <7% (53 mmol/mol) if low hypoglycaemia risk — individualise (1).
- At diagnosis screen: retinopathy (fundus), nephropathy (eGFR+ACR — already started), feet (neuropathy + pulses), lipids, BP; counsel hypoglycaemia if drugs that cause it are added later (1).
d) Name two situations in which you would start insulin early in type 2 diabetes. (2 marks)
Any two (1 each): symptomatic severe hyperglycaemia / catabolism; HbA1c very high (e.g. ≥10%) with osmotic symptoms; pregnancy; contraindication/intolerance to orals; hyperglycaemic crisis (DKA/HHS); perioperative needs; latent autoimmune suspicion.