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Chapter 61. Diabetes Mellitus

JR is a 68-year-old African American man with a new diagnosis of T2DM. He was classified as having prediabetes (at risk for developing diabetes) 5 years before the diagnosis and has a strong family history of T2DM. JR’s blood pressure was 150/92 mm Hg. His laboratory results revealed an A1c of 9.2%, glucose of 279 mg/dL, cholesterol panels renal/hepatic function were normal today.

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Past Medical History

Hypertension (diagnosed 4 years ago)

Hyperlipidemia (diagnosed 2 years ago)

Pancreatitis [idiopathic] (acute hospitalization 3 years ago)

Family History T2DM
Medication HCTZ 25 mg daily, Simvastatin 10 mg daily
Vitals

BP: 150/92 mm Hg, P: 78 beats/min, RR: 12

Waist circumference 46 inches

Weight: 267 lb

Height: 5’ 6”

BMI: 43.1 kg/m2

Six weeks later, JR returns to obtain new labs results. He tests his blood glucose and blood pressures at home. Within the last 4 weeks he has started an exercise program 4 times per week consisting of cardio/resistant training for 40 minutes per session. JR indicates he is motivated to beat this and has reviewed a lot of educational material about diabetes.

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Home blood pressure (mm Hg): [electronic cuff/sitting/right arm] 150/85, 161/74, 152/82, 148/83, 156/71, 150/74
Home fasting blood glucose readings (mg/dL) 278, 218, 219, 119, 156, 193

Today’s Labs and Vitals

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A1c → 8.1% Fasting glucose → 176 mg/dL
Total cholesterol → 201 mg/dL LDL cholesterol → 124 mg/dL
SCr → 0.98 mg/dL Na → 138 mEq/L, K → 4.3 mEq/L
Albumin-to-creatinine ratio: 152 mg/g creatinine
BP: 148/92 mm Hg P: 75 beats/min

Due to elevated home and clinic blood pressure readings it has been decided a second blood pressure medication is needed. Which agent would be the best to start in order to achieve blood pressure control and prevent microvascular complications?

a. Clonidine 0.1 mg twice daily

b. Isosorbide mononitrate 60 mg daily

c. Lisinopril 5 mg daily

d. Terazosin 10 mg at bedtime

Answer c is correct. Lisinopril is an angiotensin-converting enzyme inhibitor and considered to be a drug of choice for renal protection in patients with diabetes with noted increase albumin excretion. ACEi and ARBs have demonstrated to reduce renal progression to overt proteinuria. African American’s may not see the maximum effect of blood pressure lowering with ACEi due to a decrease amount of renin.

Answer a is incorrect. Clonidine does not have supporting data indicating renal protection for patients with diabetes. Dose provided would be an appropriate starting dose.

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