Case 1: 47-Year-Old Male

• Demographics: Asymptomatic; BMI = 36.5 kg/m²

• Medical History:

  • Type 2 diabetes mellitus (1 year, treated with Metformin)

  • Congenital urethral stricture, frequent UTIs

• Lab Findings:

  • FPG: 111 mg/dL, 115 mg/dL

  • Postprandial PG: 180-208 mg/dL

  • HbA1c: 7.5%

  • C-peptide: 3 nmol/L

  • Triglycerides: 100 mg/dL

• Glycemic Targets:

  • Fasting: 80-130 mg/dL

  • Postprandial: <180 mg/dL

  • HbA1c: 6.5% with low hypoglycemia risk

• Arguments:

  • Long life expectancy (age 47)

  • Short diabetes duration (1 year)

  • No vascular complications

  • Mild comorbidities (recurrent UTIs)

  • Good support system

  • Highly motivated, adherent

  • Risk of hypoglycemia due to fluctuating meal schedule

• Treatment Goals:

  • Reduce HbA1c (focus on postprandial values)

  • Avoid hypoglycemia

  • Promote weight loss

• Therapeutic Options:

  • Lifestyle changes: 4-5 meals/day, reduced carbs, regular exercise

  • Continue Metformin at 2 g/day

  • If needed, add GLP-1 receptor agonists (low hypoglycemia risk)

Case 2: 61-Year-Old Male

• Demographics: Associate professor, BMI = 38.7 kg/m²

• Medical History:

  • Type 2 diabetes (8 years, treated with Metformin and Gliclazide)

  • Cardiac issues (Myocardial infarction, bypass surgery)

• Lab Findings:

  • FPG: 111 mg/dL, fluctuating Random glucose levels

  • HbA1c: 7%

  • Triglycerides: 545 mg/dL

• Glycemic Targets:

  • Fasting: 100-150 mg/dL

  • Postprandial: <190 mg/dL

  • HbA1c: 7% or 6.5%

• Arguments:

  • Medium life expectancy (age 61)

  • Duration of diabetes (8 years)

  • Cardiovascular complications present

  • Risk of hypoglycemia from Gliclazide

• Treatment Goals:

  • Lower HbA1c, especially postprandial values

  • Cardiovascular safety

  • Weight loss

• Therapeutic Options:

  • Lifestyle optimization

  • Metformin: maintain 2 g/day

  • Discontinue Gliclazide (risk of hypoglycemia)

  • Consider SGLT2 inhibitors for efficacy and safety

Case 3: 65-Year-Old Male

• Demographics: Sales manager, BMI = 30.7 kg/m²

• Medical History:

  • Type 2 diabetes (10 years, treated with Dapagliflozin & Metformin)

  • Complications: Unproliferative diabetic retinopathy

• Lab Findings:

  • FPG: 69-125 mg/dL

  • HbA1c: 6.5%

  • Creatinine: 3.9 mg/dL, eGFR: 15.2

• Glycemic Targets:

  • Fasting: 100-150 mg/dL

  • Postprandial: <190 mg/dL

  • HbA1c: 7% or 6.5%

• Arguments:

  • Medium life expectancy (age 65)

  • Presence of chronic complications

  • Acute renal injury and CKD

• Treatment Goals:

  • Avoid hypoglycemia

  • Renal safety

• Therapeutic Options:

  • Discontinue Metformin and Dapagliflozin (low eGFR)

  • Treat urinary infection

  • Consider GLP-1 receptor agonists based on eGFR

Case 4: 45-Year-Old Female

• Demographics: Jaundiced, vomiting, abdominal pain

• Medical History:

  • Type 2 diabetes (5 years, treated with Gliclazide & Metformin)

  • Recent blood transfusion

• Lab Findings:

  • FPG: 100-110 mg/dL

  • HbA1c: 6.3%

  • ALT: 989 U/L, AST: 952 U/L

• Glycemic Targets:

  • Fasting: 80-130 mg/dL

• Arguments:

  • Long life expectancy

  • Short diabetes duration

  • Moderate comorbidities (acute hepatitis B)

• Treatment Goals:

  • Avoid hypoglycemia

  • Ensure hepatic safety

• Therapeutic Options:

  • Discontinue Metformin and Gliclazide due to hepatic failure

  • Initiate insulin therapy

Case 5: 77-Year-Old Female

• Demographics: Lives alone, visual impairment

• Medical History:

  • Type 2 diabetes (diagnosed for 1 month)

  • History of trophic ulcer

• Lab Findings:

  • Plasma glucose: 300-397 mg/dL

  • HbA1c: 13.9%

• Glycemic Targets:

  • Fasting: 100-170 mg/dL

  • HbA1c: 7.5-8%

• Arguments:

  • Short life expectancy (age 77)

  • Long duration of undiagnosed diabetes

  • Vascular complications present

• Treatment Goals:

  • Reduce HbA1c

  • Avoid hypoglycemia

  • Treat infected ulcer

• Therapeutic Options:

  • Start insulin therapy due to ketosis and hyperglycemia

Individualization of Glycemic Targets

• Considerations:

  • Stricter targets for younger, low-risk groups

  • Less stringent for older, high-risk patients

  • Evaluate comorbidities, life expectancy, and patient motivation

  • Resources and support system availability important

Pharmacological Therapy Overview

• Metformin:

  • Mechanism: Decreases hepatic insulin resistance

  • Side Effects: Gastrointestinal issues, risk of lactic acidosis

• SGLT2 Inhibitors:

  • Benefits: Weight loss, reduction in BP

  • Side Effects: Risk of infections, dehydration

• GLP-1 Receptor Agonists:

  • Benefits: Weight loss, reduces postprandial glycemia

  • Side Effects: Nausea, injections

• DPP-4 Inhibitors:

  • Neutral for weight effects, slight risk of joint pain

• Alpha Glucosidase Inhibitors:

  • Reduce glucose absorption, side effects: Gastrointestinal issues

• Sulfonylureas:

  • Stimulate insulin secretion, risk of significant hypoglycemia

• Glinides:

  • Moderate risk of hypoglycemia, weight gain

Management of Diabetes in Kidney Disease

• eGFR Categories:

  • Adjust medications based on kidney function

  • Contraindications present for certain therapies in advanced CKD.