Endgames Case report

A taxi driver with type 2 diabetes

BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b1369 (Published 29 April 2009) Cite this as: BMJ 2009;338:b1369
  1. Richard Brice, general practitioner
  1. 1Whitstable Medical Practice, Whitstable, Kent CT5 1BZ
  1. richard.brice{at}gp-g82071.nhs.uk

    A 56 year old male taxi driver with a four year history of type 2 diabetes visited the surgery because he was fed up with trying to control his blood glucose. Although his most recent glycated haemoglobin measurement of 7.4% a month ago indicated that glycaemic control was reasonable, he was frustrated by weight gain, several recent hypoglycaemic episodes, and the number of tablets he had to take each day. He was beginning to wonder “whether it’s all worthwhile.”

    He had no current diabetic complications, and recent renal and liver function blood tests had been normal. His body mass index was 33.2, blood pressure was 130/80 mm Hg, total cholesterol was 3.9 mmol/l, and high density lipoprotein was 1.3 mmol/l. He was taking metformin 1 g twice a day, gliclazide 160 mg twice a day, aspirin 75 mg once a day, simvastatin 40 mg at night, ramipril 10 mg once a day, and amlodipine 10 mg once a day.

    Questions

    • 1 How would you approach this consultation?

    • 2 Would it be beneficial for him to reduce his glycated haemoglobin value?

    • 3 What problems does his job pose when aiming for good glycaemic control and how should his drugs be changed because of these problems?

    Answers

    Short answers

    • 1 Ascertain what outcomes he hopes for from the consultation, and try to integrate these with your desired outcomes. Reinforce the importance of good management of chronic disease. Offer referrals to structured education and dietetic services.

    • 2 Published evidence supports efforts to lower glycated haemoglobin to 7.0%, and this is reflected by some, but not all, of the national and international guidelines. Evidence for pursuing a more aggressive target of <7.0% is limited, and the two recently published large scale randomised controlled trials studying such an approach gave conflicting results.

    • 3 The patient drives for a living, …

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