Skill Checkup: A 71-Year-Old Man With History of Type 2 Diabetes and Related Hypertension Experiences Retrosternal Pressure

Carolyn Newberry, MD, PNS


December 21, 2022

The patient's antihyperglycemic regimen was not the only area where his management was not consistent with current treatment guidelines from the ADA and others. This patient also likely could benefit from reinforcement of nutrition therapy and lifestyle modifications. As noted, patients with T2D are at elevated risk for CV events and ASCVD independent of any other risk factors they may have. As such, recommended medical management includes multiple pathways to reduce their risk for MACE or other outcomes.

According to ADA guidelines, all patients aged 45-75 years with T2D without confirmed ASCVD should be on a moderate-intensity or high-intensity statin as primary prevention; those of any age with confirmed ASCVD should be on a high-intensity statin as secondary prevention.

In patients with T2D and CAD, the ADA recommends ACE inhibitors and angiotensin receptor blockers as a first-line approach to hypertension and are preferred antihypertensives for patients with CAD. Ideally, this patient would be treated to achieve systolic blood pressure/diastolic blood pressure < 130 mm Hg owing to presence of CAD.

The patient also has obesity (BMI, 30.1 kg/m2). Management of obesity for patients with T2D includes many steps that overlap with T2D management, including nutrition and physical exercise counseling. Sustained weight loss of at least 5% of body weight is associated with improvements in blood pressure, glycemic control, and lipids in patients with T2D and obesity. Ideally, such weight loss is obtained with lifestyle modifications, but often pharmacotherapy is needed as well. Initiation of a GLP-1 RA at the diabetes dosage for this patient may help him achieve the goal, but if more intense pharmacotherapy is necessary, he could be managed with the higher-dose obesity formulations. Two GLP-1 RAs (once-daily liraglutide and once-weekly semaglutide) have higher dosage formulations that are Food and Drug Administration-approved for weight loss in patients with obesity, including patients with T2D. These drugs are recommended by ADA for patients with BMI ≥ 27 mg/k2 and T2D.

Phentermine is an approved obesity medication but associated with increased blood pressure and heart rate, making it a poor choice for this patient.

Bariatric or metabolic surgery can be effective for patients with severe obesity and T2D, although it is relatively contraindicated for geriatric patients. It should be considered for patients with BMI ≥ 40 kg/m2 (or ≥ 37 kg/m2). It also can be considered for patient with less severity if they have obesity-related complications or cannot achieve significant weight loss or improvement in risk factors with medical and lifestyle therapy. This patient hasn't yet had a chance to improve his T2D, CV risk factors, and obesity with guideline-directed therapy, so surgery is not yet an option.

Editor's Note: Skill Checkups are wholly fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

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