Pacific patients and T2D: How can we do better?

Mr M is a 44 year old Samoan man who arrives 20 minutes late to his Saturday morning appointment. Your nurse asks if you can fit him in, as she has been trying unsuccessfully to contact him about his HbA1c, which was 104 mmol/mol at the last check 6 months ago.

Mr M was diagnosed with type 2 diabetes 5 years ago with an HbA1c of 72 mmol/mol. He has since been seen irregularly by multiple GPs. Despite advice about diet and exercise, his HbA1c continued to increase, and two years ago, he was prescribed Galvumet (vildagliptin/metformin) 50mg/1000mg twice daily.

However, repeat prescriptions have been irregular and the most recent one was 6 months ago. At that visit, his weight was 134kg (height 180cm, BMI 41), blood pressure was 154/94mmHg. What do you do next?

Visit 1: Build rapport, re-establish treatment and arrange regular reviews

Mr M apologises for arriving late. He tells you he works night shifts and finished late today. On examination, he weighs 140kg, and his blood pressure is 158/90mmHg. His cardiorespiratory and foot examinations are normal. You move on to discussing management, focusing on:

• The high risk of diabetes complications if HbA1c remains high. Mr M tells you his father used insulin but needed dialysis and bilateral foot amputations anyway. You spend some time discussing how effective treatments can prevent such outcomes and the importance of gaining control over diabetes quickly by using lifestyle changes, multiple oral medications and, eventually, insulin. You agree on an initial target HbA1c of <80 mmol/mol.  (NOTE: you plan to reduce this over time but aim for a motivational target at the first visit).
   
• Weight loss. You explain how significant weight loss can reverse type 2 diabetes. Mr M tells you he is drinking 2L of Coke to stay awake during his night shifts. He agrees to switch to zero-sugar Coke instead and to look for other ways to limit his sugar intake. You also offer a referral to Green Prescription, which he declines due to his incompatible work schedule. However, he plans to work out with weights in his garage three times per week and to return for regular weight checks every month. You also raise the idea of bariatric surgery and agree to discuss this further after trying diet and exercise.
   
• Medications. Mr M has stopped taking his current tablets but is willing to restart. You want to escalate treatment quickly given the high HbA1c, so you add a dose of empagliflozin 10mg once daily, after counselling him about starting empagliflozin. You also restart losartan 50mg daily and ask Mr M to have a blood test in two weeks (renal function, ACR, LFTs and cholesterol for CVD risk assessment).
   
• Regular reviews. You ask Mr M how you can see him regularly and he suggests later on Saturday mornings work best. You offer discounted visits (using your PHO’s flexible funding budget) and book a 30-minute review with you in two weeks. You also arrange for your nurse to call him next week to check in.

Visit 2: Titrate medications, start blood glucose monitoring, CVD risk assessment and blood pressure control

Mr M brings his wife to this appointment and you spend a few minutes getting to know her. She does the family food shopping and cooking and you discuss healthy eating for the family. Next, you review the blood test results with the following actions:

• HbA1c 88 mmol/mol. Mr M is tolerating empagliflozin well and is pleased to see a drop in HbA1c, however, you need to keep reducing HbA1c so agree to increase the empagliflozin to 25mg once daily. You explain that this will likely reduce the HbA1c further, but not enough to reach the new target of <68mmol/ml. You ask him to start regular blood glucose testing at home in preparation for starting insulin and prescribe a testing meter. You book him a review with the nurse tomorrow to learn about target blood glucose levels and how to use the meter.
   
• eGFR 60 mL/min and ACR 3.5 mg/mol. You complete a cardiovascular disease risk assessment which shows a 5-year risk of >15%. You discuss the significance of microalbuminuria on the kidneys and blood vessels  and agree on a target blood pressure of <130/80 mmHg. Today’s blood pressure is 152/90 mmHg. Mr M is tolerating losartan well and you explain the need to increase therapy. Mr M is reluctant to take another pill, so you offer the combination losartan/hydrochlorothiazide 50mg/12.5mg after first discussing the risks of taking NSAIDs while on this medication and recommending he avoids them. You also ask him to monitor for symptoms of gout and arrange a repeat blood test in two weeks to check renal function.
   
• Total cholesterol 6.2 mmol/L and HDL 0.7 mmol/L. You discuss how exercise can increase HDL and suggest a statin for hyperlipidaemia. However, Mr M declines as he doesn’t want any more tablets so you defer this for now. 
   
• Weight 138kg. Mr M is doing well with his diet and exercise but progress is slow. He has spoken with friends who have had bariatric surgery and would like to be referred.

Visit 3: Start insulin and titrate antihypertensive medication

Mr M’s renal function is satisfactory on the escalated antihypertensive treatment and he is tolerating empagliflozin well. You review his blood glucose readings from the previous 3 days:

You start Mr M on a regimen of 10 units isophane (Humulin NPH) at bedtime and plan for him to continue the empagliflozin. You ask him to continue testing fasting blood glucose levels every morning initially, and plan for a patient-led titration whereby he will increase the insulin dose by 2 units every 3 days until fasting levels are within the target range of 6.1-7.9 mmol/L range. Once at target, he can reduce blood glucose testing to twice weekly.

You arrange weekly nurse follow-up by phone and ask him to return to see you in four weeks days for review. You ask him to measure pre-breakfast and pre-dinner blood glucose levels on the 3 days before your visit to allow dose titration.

Mr M and his wife then go to see your nurse to learn how to inject, store and handle insulin. They also discuss symptoms of hypoglycaemia and meal timings.

Ongoing management: Titrate insulin and antihypertensive medications to targets, continue weight management

Over time, you monitor blood glucose levels to ensure the evening isophane dose is optimised to achieve fasting (pre-breakfast) levels.

However, you notice that despite adequate fasting levels the daytime readings are increasing, and pre-dinner readings are consistently above 10 mmol/L. At this stage you have the option to add morning isophane or switch to glargine at night; check NZSSD Insulin Algorithm Guidelines, the RACGP diabetes handbook, or Health Pathways for details on how to do this.

You continue to help Mr M manage his weight, blood pressure and cholesterol, with regular reviews and nurse phone-calls in between visits.