My patient has had diabetes since her last pregnancy. Her postprandial blood sugar was 186 mg/dl [10.3 mmol/L] on March 29, 2005. Her A1c was 8.6. Bl Urea was 28 Mb; S. Creatinine was 1.0; R. Bl sugar 212; lipid profile (total cholesterol 200, Triglycerides 178, HDL 41, HDL 124, VLDL 35 mg, total lipids 592, Cholesterol/HDL ratio 4.8, LDL/HDL Cholesterol ratio 3.0); Urine R & M Albumin trace; and Sugar +++. Her blood pressure was 190/110. She is taking one metformin tablet daily, one 50 mg tablet of losartan, one 2.5 mg tablet of ramipril and a vitamin of B1, B6 and B12. Do you have any advice?

Your patient is being treated for type 2 diabetes. Is this patient young and thin? You need to make sure she has type 2 diabetes. A measurable C-peptide would be helpful here to make sure she indeed has type 2 diabetes and not type 1 diabetes. If she does indeed have type 2 diabetes, her blood sugars are too high. The A1c suggests the metformin should be increased to 500 mg twice a day to 1000 mg twice a day. This is providing she can tolerate the medicine and has no contraindications to taking it. Her blood pressure is too high in the presence of albuminuria. The ramipril should be increased to titrate to a blood pressure to less than 130/80 mm Hg. Finally, her LDL-cholesterol is too high. Consideration should be given to statin therapy to lower the LDL-cholesterol to levels less than 100 mg/dl.

JTL