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.