Case study 1: Remission of Type 2 diabetes
Type 2 diabetes prescribing
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.
