Sponsored information from

Primary care Action Interactive Cases

Return to homepage 

Sofia, 70

Sofia is a 70-year-old female who is retired and previously worked as a teaching assistant.

She is visiting you for a regular type 2 diabetes (T2D) check-up.

Patient history

  • T2D diagnosis 12 years ago
  • Metformin (12 years), SGLT-2i (4 years), GLP-1 RA (2 years): all at optimum/ maximally tolerated dose
  • Non-smoker, minimal alcohol intake
  • Hypertension, 10 years (CCB, 8 years)
  • Dyslipidaemia, 8 years (statin, 8 years; ezetimibe, 2 years)
  • HbA1c target: <7.5%
  • Over the last year has refused recommended treatment intensification with basal insulin

Current clinical measurements

  • BMI 32 kg/m2 (4 months prior: BMI 32 kg/m2)
  • HbA1c 8.5% (69 mmol/mol)
  • BP 128/79 mmHg
  • LDL cholesterol 1.4 mmol/L (54 mg/dL)
  • ALT 28 U/L and AST 25 U/L
  • FIB-4 score 1.1 (learn more )
  • eGFR 75 mL/min/1.73 m2

ALT: alanine aminotransferase; AST: aspartate aminotransferase; BMI: body mass index; BP: blood pressure; CCB: calcium channel blocker; eGFR: estimated glomerular filtration rate; FIB-4: Fibrosis-4 index; GLP-1 RA: glucagon-like peptide-1 receptor agonist; LDL: low-density lipoprotein; SGLT-2i: sodium-glucose cotransporter-2 inhibitor; T2D: type 2 diabetes

Hide medical notes 
Clinical data 

This is a fictional case study. The model is not a real patient and the situation shown does not reflect the model's experience.

References
  1. Vieira Barbosa J, Milligan S et al. Fibrosis-4 index as an independent predictor of mortality and liver-related outcomes in NAFLD. Hepatol Commun 2022;6(4):765-779
  2. Loomba R, Adams L A. The 20% rule of NASH progression: the natural history of advanced fibrosis and cirrhosis caused by NASH. Hepatology 2019;70(6):1885-1888
  3. Sterling R K, Lissen E et al. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Hepatology 2006;43(6):1317-1325
  4. Reach G, Pechtner V et al. Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus. Diabetes Metab 2017;43(6):501-511
  5. Hosomura N, Malmasi S et al. Decline of insulin therapy and delays in insulin initiation in people with uncontrolled diabetes mellitus. Diabet Med 2017;34(11):1599-1602
  6. Davies M J, Aroda V R et al. Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2022:doi:10.2337/dci2322-0034
  7. Khunti K, Gomes M B et al. Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: a systematic review. Diabetes Obes Metab 2018;20(2):427-437
  8. Bailey R A, Shillington A C et al. Changing patients' treatment preferences and values with a decision aid for type 2 diabetes mellitus: results from the treatment arm of a randomized controlled trial. Diabetes Ther 2018;9(2):803-814
  9. Davies M J, D'Alessio D A et al. Management of hyperglycemia in type 2 diabetes, 2018. a consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2018;41(12):2669-2701
  10. Kulzer B, Daenschel W et al. Integrated personalized diabetes management improves glycemic control in patients with insulin-treated type 2 diabetes: results of the PDM-ProValue study program. Diabetes Res Clin Pract 2018;144:200-212
  11. Cersosimo E, Johnson E L et al. Initiating therapy in patients newly diagnosed with type 2 diabetes: combination therapy vs a stepwise approach. Diabetes Obes Metab 2018;20(3):497-507
  12. Nuffer W, Guesnier A, Trujillo J M. A review of the new GLP-1 receptor agonist/basal insulin fixed-ratio combination products. Ther Adv Endocrinol Metab 2018;9(3):69-79
  13. Zonszein J, Groop P H. Strategies for diabetes management: using newer oral combination therapies early in the disease. Diabetes Ther 2016;7(4):621-639
  14. Khunti S, Khunti K, Seidu S. Therapeutic inertia in type 2 diabetes: prevalence, causes, consequences and methods to overcome inertia. Ther Adv Endocrinol Metab 2019;10:2042018819844694
  15. Paul S K, Klein K et al. Delay in treatment intensification increases the risks of cardiovascular events in patients with type 2 diabetes. Cardiovasc Diabetol 2015;14:100
  16. Polonsky W H, Arsenault J et al. Initiating insulin: how to help people with type 2 diabetes start and continue insulin successfully. Int J Clin Pract 2017;71(8):e12973
  17. Medicine Matters: diabetes. Young C. When you need to have a conversation with your patient about starting insulin... Available at: diabetes.medicinematters.com. Accessed March 2023
  18. Diabetes UK. Chapter 5: pscyhological barriers to insulin use. Available at: diabetes.org.uk. Accessed March 2023
  19. Stuckey H, Fisher L et al. Key factors for overcoming psychological insulin resistance: an examination of patient perspectives through content analysis. BMJ Open Diabetes Res Care 2019;7(1):e000723
  20. Peyrot M, Barnett A H et al. Insulin adherence behaviours and barriers in the multinational Global Attitudes of Patients and Physicians in Insulin Therapy study. Diabet Med 2012;29(5):682-689
  21. Blonde L, Meneghini L et al. Probability of achieving glycemic control with basal insulin in patients with type 2 diabetes in real-world practice in the USA. Diabetes Ther 2018;9(3):1347-1358
  22. Baxter M, Morimoto Y et al. A real-world observational study evaluating the probability of glycemic control with basal insulin or glucagon-like peptide-1 receptor agonist in Japanese patients with type 2 diabetes. Diabetes Ther 2020;11(7):1481-1496
  23. Blonde L, Brunton S A et al. Achievement of target A1C <7.0% (<53 mmol/mol) by U.S. type 2 diabetes patients treated with basal insulin in both randomized controlled trials and clinical practice. Diabetes Spectr 2019;32(2):93-103
  24. Liebl A, Jones S et al. Clinical outcomes after insulin initiation in patients with type 2 diabetes: 6-month data from the INSTIGATE observational study in five European countries. Curr Med Res Opin 2011;27(5):887-895
  25. Zhang P, Chen M et al. Effectiveness and safety of basal insulin therapy in type 2 diabetes mellitus patients with or without metformin observed in a national cohort in China. BMC Endocr Disord 2022;22(1):26