Real life complex patient: NICE on diabetes, hypertension, hypertriglyceridemia and hypothyroidism Diabetes in Primary Care

My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a real-life case to demonstrate how the guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals and you must use your clinical judgement.
The PDF version of this episode can be found here:
·      Colour version: https://1drv.ms/b/s!AiVFJ_Uoigq0l3MBwm5sUpEybW8r?e=xio6pz
·      Printer friendly version: https://1drv.ms/b/s!AiVFJ_Uoigq0l3RhABLRM2_pQQOz?e=jzuMxb
There is a YouTube version of this and other videos that you can access here:
·      The NICE GP YouTube Channel: NICE GP - YouTube
Prescribing information links:
·      Website: https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/dpp-4-inhibitors/
·      Download PDF: https://1drv.ms/b/s!AiVFJ_Uoigq0liBvuQq8_0Cd-GSz?e=NnL56J
·      Website: https://cks.nice.org.uk/topics/diabetes-type-2/prescribing-information/glp-1-receptor-agonists/
·      Download PDF: https://1drv.ms/b/s!AiVFJ_Uoigq0liFRycIZPaVfj-lC?e=a2QTNY
 
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Transcript
Hello everyone and welcome. My name is Fernando and I am a GP in the United Kingdom.
We have looked at fictitious patients in previous episodes but, in today’s episode, I am going to look at a real diabetic case to see how the guidelines could apply to it. And as you know, we are focusing only on the pharmacological treatment. If you want to download a PDF version of this episode, the link is in the episode description. 
Please note that I am not giving medical advice; this is only my interpretation of the guidelines and you must use your clinical judgement 
Remember that there is also a Youtube version of these episodes so have a look in the episode description.
Right, so let’s get straight into it. The details, which have been anonymised, belong to a real patient, so we have 46-year-old man of Asian descent with T2DM who presents with the following: 
HbA1c is 68 mmols/mol/8.4% (therefore poorly controlled) Cholesterol 5.9 Triglycerides 5.72 HDL 0.97 ·      The path lab has not calculated LDL because triglycerides >4.5 
·      Liver and Renal function tests are normal with an eGFR of 97  
Thyroid function tests show a borderline low T4 of 9 (NR 9-19.1) and a raised TSH of 9.88 (NR 0.35-4.94 ACR normal FBC and other routine blood tests were normal.  His BMI is 32, so he is obese His BP is 147/89 His PMH includes: Hypothyroidism T2DM His regular treatment is with: Levothyroxine 200mcg daily Metformin 500 mg TDS He comes to discuss his test results, feeling well in himself. His obesity is long-standing and being managed with diet and lifestyle advice. He has had hypothyroidism for 15 years and, on prompting, he says that he is feeling a little tired 
So, let’s have a look at the guidelines. As usual I will focus on the NICE guidelines and we will have to looks at the guidelines on type 2 diabetes, hypertension, prevention of cardiovascular disease, and hypothyroidism  
Let’s look at his diabetes first. 
Firstly, NICE says that we need to consider if rescue therapy is necessary for symptomatic hyperglycaemia with insulin or a sulfonylurea. However, he is well and asymptomatic so we do not have to do this. 
We see that his current dose of metformin 500 mg 3 times a day is not enough to control his diabetes. So, given that his renal function is completely normal.  we should increase the dose to the maximum of 2000mg daily, that is, 1000mg twice a day. However, this is unlikely to be enough to bring his HbA1c of 68 or 8.4% to target. And let’s remember that according to NICE we should strive for the following targets: 
·      Li