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Diabetic with hypertension and hyperlipidemia. Taking metformin. What should be the management plan?

HI How to manage a case of type 2 diabetes patient with co morbid hypertension and borderline hyperlipidemia and failed to achieve glycemic goals with diet and lifestyle modifications and metformin . Also let me know the further evaluation of this patient and management plan (elaborating on most suitable pharmacological agents).
Asked On : Fri, 15 Mar 2013
Answers:  3 Views:  99
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General & Family Physician 's  Response
Hello,
Since your diet and lifestyle modifications have failed to achieve the desired results,it would be prudent to start proper medicine treatment to avoid unnecessary complications.
Without examining you ,it is not possible for any doctor to design the treatment plan for you and that too online.
More realistic approach for you would be to consult a diabetologist,get properly examined and investigated further for example eye examination and cardiac assessment ,and then take the treatment.
It is believed that co existing dyslipidemia significantly contributes to higher prevalence of macro vascular disease and thus needs to be aggressively managed along with hyperglycemia and hypertension.
I would restrict myself for the goals to be achieved by you..
Keep your HBA1c to below 7
Keep your blood pressure below 120/80 mm og Hg.
LDL should be below 80
Triglycerides to be below 150.
Must carry on with dietary restrictions and other lifestyle modifications ,even after start of medications.
Thanks
Answered: Fri, 15 Mar 2013
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General & Family Physician Dr. Jay Patel's  Response
Hi,

1) Well their is new drug alogliptin can be used with combination of metformin,
(Alogliptin is a DPP-4 inhibitor which delays the break down of IGF) Studies have shown 6-10% improvement in patients on only ALOGLIPTIN - But synergy with metformin works very good.

2) NEXT is Sulfonylurea (Stimulating insulin release by pancreatic beta cells by inhibiting the KATP channel) but has little higher risk then metformin,

3) ACARBOSE -Reduces glucose absorbance by acting on small intestine to cause decrease in production of enzymes needed to digest carbohydrates - (less effective than most other diabetes pills in decreasing glycated hemoglobin)

4) Thiazolidinediones- Reduce insulin resistance by activating PPAR-γ in fat and muscle (side effects to be seen in this case increased risk of heart failure,causes an average of 2-5kg weight gain)

5) IF nothing works then " INSULIN" IS The last option as it need to be injected so people tend to keep it as a last weapon in arsenal.
Answered: Fri, 15 Mar 2013
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Cardiologist Dr. Hemant Kumar's  Response
DM TYPE 2 GOAL--- FASTING SUGAR 100-110 , PP - 160-180

HYPERTNSION GOAL IN DM --- BP SHOULD BE BELOW 130/80 MMHG ( ACE INHIBITORS OR ARB ARE DRUG OF CHOICE )

HYPERLIPIDEMIA--- GOAL IS TO LDL BELOW 100 EVEN NORMAL LIPID LEVEL, ATRORVASTATIN SHOULD BE STARTED ( BECAUSE DIABETIC IS ISCHEMIC HEART DISEASE EQUIVALENT)

YOU SHOULD GO FOR-- ECG/ECHO/TMT/URINE PROTEIN 24 HOUR / HB1AC/ UREA/CREATININE
Answered: Fri, 15 Mar 2013
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