Case study 1: Remission of Type 2 diabetes

Background (age, sex, occupation, baseline function)

57 years old
Male
Self-employed taxi driver

History of presentation/reason for review

Referral to Weight Management Service from GP
Reports that he “drank and ate too much in his 20’s” but active in his job. Since becoming a taxi driver and quitting smoking his weight increased
Works 12 hour shifts 5-6 days a week, leaving little time for physical activity
Tried commercial slimming clubs in the past but regained weight once stopped attending
Reports overeating in response to stress
Does no cooking at home – meals mostly on the go, grabbing convenience foods whilst driving his taxi

Current medical history and relevant co-morbidities

T2DM diagnosed 3 years ago
Essential hypertension
Gastro-oesophageal reflux disease (GORD)
Depressive disorder
Family history of CVD and T2DM with a family member requiring an amputation due to peripheral vascular disease
High stress levels during the COVID-19 pandemic and lack of income

Current medication and drug allergies (include OTC preparation and herbal remedies)

Candesartan 8mg tablets - one tablet daily
Metformin 500mg tablets – two tablets twice daily
Sildenafil 100mg tablets - one tablet daily as required
Trazadone 50mg capsules - one capsule at night

Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity

Alcohol – social drinker
Ex-smoker
Physical activity level low – struggles to walk any distance without pain

“What matters to me” (patient ideas, concerns and expectations of treatment)

His own aims are to put his Type 2 diabetes into remission, stop his medications and improve his mobility and quality of life

Results e.g., biochemistry, other relevant investigations or monitoring

Height 1.85m
Weight 148.6kg
BMI 43.4 kg/m2
HbA1c 67mmol/mol.
Blood pressure normal range on antihypertensive medication
LDL cholesterol 3.3mmol/L

Most recent relevant consultations

Attended a few appointments with team psychologist prior to starting the intervention. Discussed concerns around eating behaviours including boredom/comfort eating and high stress levels
Placed on the NHS Scotland/Counterweight Plus Remission Programme - total diet replacement (TDR) – 800 calorie per day soups and shakes diet (4/day) for an initial 12 weeks. Fortnightly appointments with the specialist dietitian for treatment through the programme
Metformin and candesartan stopped on day 1 of the intervention as per the agreed medical management protocol
31kg weight lost at the end of 12 weeks of TDR – blood glucose, weight and blood pressure were checked every 2 weeks at appointment with the dietitian
After 12 weeks of TDR, food was slowly reintroduced
A further 13kg was lost over the 12 weeks on the food reintroduction stage
BP medications were reintroduced due to a rebound increase in resting BP, at half the dosage at the start of the intervention
At 6 months:
- Appointments monthly
- Weight loss was 29% of body weight, 10 inches lost from waist
- Metformin stopped, BP medications dosage halved
- Patient was jogging multiple times per week – 5km distances
- HbA1c had reduced from 65 to 46 mmol/mol – now in remission.
Progressing with second year of weight loss maintenance in the type 2 diabetes remission programme, including monthly appointments with dietician
Maintaining lifestyle changes and continuing to regularly monitor measurements
- Wife attended a cooking class and supports with planning and cooking meals
- Takes meals with him in his taxi instead of buying food on the go, also helps with cooking evening meal
- Has progressed from being unable to walk round block to regularly running 5km distances
Current medications:
- Candesartan 4 mg OD
- Trazadone 50 mg
Current measurements:
- Weight: 99.9 kg
- BMI: 29.2 kg/m²
- Total weight loss: 32.7%
- HbA1c 36 mmol/mol
- Cholesterol: 2.7 mmol/l
- Remains in remission

7 Steps: Person specific issues to address for case study 2

1. Aims: What matters to the individual about their condition(s)?

Review diagnoses and consider:

Therapeutic objectives of drug therapy
Management of existing health problems
Prevention of future health issues, including lifestyle advice

Person specific actions

Reduce medication
Keep diabetes in remission

2. Need: Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice*)

Drugs that have essential replacement functions
Drugs to prevent rapid symptomatic decline

* with advice from healthcare professional with specialist interest

Person specific actions

Continue on candesartan. BP has improved with weight loss, but not enough to stop

3. Does the patient take unnecessary drug therapy?

Identify and review the continued need for drugs

what is medication for?
with temporary indications
with higher than usual maintenance doses
with limited benefit/evidence for use
with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific actions

No, but candesartan and metformin to be stopped during TDR

4. Effectiveness: Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

to achieve symptom control
to achieve biochemical/clinical targets
to prevent disease progression/exacerbation
is there a more appropriate medication to achieve goals?

Person specific actions

None required. BP within target range

5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?

Identify individual safety risks by checking for

appropriate individual targets
drug-disease interactions
drug-drug interactions (see ADR table)
monitoring mechanisms for high-risk drugs
risk of accidental overdosing

Identify adverse drug effects by checking for

specific symptoms/laboratory markers
cumulative adverse drug effects (see ADR table)
drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific actions

Candesartan and metformin should both be temporarily stopped (if these need to be reinstated)

6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?

Identify unnecessarily costly drug therapy by

considering more cost-effective alternatives, safety, convenience -

Consider the environmental impact of

Inhaler use
Single use plastics -
Medicines waste
Water pollution

Person specific actions

None - prescribing in keeping with current formulary recommendations
Patient advised to dispose of medicines through community pharmacy
Advised patient to only order what is needed, do not stockpile medicines

7. Patient centeredness: Is the patient willing and able to take drug therapy as intended?

Does the person understand the outcomes of the review?

Consider teach-back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

is the medication in a form they can take?
is the dosing schedule convenient?
what assistance is needed?
are they able to take medicines as intended?

Agree and communicate plan

discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
include lifestyle and holistic management goals
inform relevant health and social care providers of changes in treatments across the transitions of care

Person specific actions

If HbA1c increases consider review and introduce diabetic medications

Key concepts in this case

Lifestyle and dietary changes enabled remission of diabetes and stopping medication.
Mood, self-confidence, self-esteem and relationships have all improved through a combination of more physical activity and mobility, remission of long term condition and reduction in medications/doctors’ appointments.

Click on the table image to view a PDF version of the full 7 steps table.