A Case of Worsening Glucose Control in Diabetes Mellitus

Case Presentation

A 62-year-old male patient is referred to you by his primary care physician because of worsening glycemic control in the context of known type 2 diabetes mellitus.

The referral notes indicate stable glycemic control over the past two years with metformin 500 mg twice daily and empagliflozin 10 mg once daily, with an HbA1c (= A1C) consistently around 7.2%.

Over the past six months, A1C has increased to 8.6%, and three months later to 9.1%. Six months ago, in response to the initial rise in A1C, the primary care physician increased the metformin dose to 1000 mg twice daily.

The patient was advised to perform capillary blood glucose measurements three times/day on two days of the week. The recorded values are shown below.

Capillary Blood Glucose Measurements in mmol/l

Referral & Emergency Evaluation

Capillary Blood Glucose Measurements in mg/dl

History

The patient reports that his type 2 diabetes was diagnosed approximately eight years ago during a routine check-up. Initially, the condition was managed with lifestyle modifications, but metformin was initiated after six months of persistent hyperglycemia. His weight remained stable for the first seven years following diagnosis; over the past year, he has gained approximately 5 kg, reaching 95 kg. To date, his treatment has included only metformin and empagliflozin, with no significant adverse effects reported. His medical history is otherwise notable for hypertension, dyslipidemia, and benign prostatic hyperplasia, for which he takes lisinopril, rosuvastatin and tamsulosin daily.

The patient confirms consistent adherence to metformin but, upon direct questioning, admits that he has been skipping empagliflozin due to concerns about urinary tract infections related to his prostate condition. He did not disclose this to his primary care physician, fearing he might disappoint him. He reports no symptoms suggestive of depression or cognitive impairment, and none were observed during the consultation.

There are no historical indications of insulin deficiency or pancreatic disease. He has not experienced weight loss, fever, malaise, or other symptoms suggestive of pancreatic cancer. As mentioned, he gained 5 kg over the past year and acknowledges neglecting lifestyle measures, including increased snacking, higher carbohydrate intake, and sugary beverages. There are no current signs or symptoms of infection, and he is not taking medications known to induce insulin resistance.

Clinical Exam

The clinical assessment revealed:

• Vital signs: Blood pressure 146/87 mmHg, heart rate 78/min, temperature 36.2 °C. These values indicate he is hemodynamically stable, without fever or hypotension.
  
  

• Anthropometrics: Height 177 cm, weight 95 kg, BMI 30.1 kg/m², waist circumference 103 cm.
  
  

• Skin and metabolic signs: No acanthosis nigricans observed.
  
  

• Signs of hypercortisolism: None detected. There is no evidence of proximal muscle wasting, facial plethora, or central obesity beyond baseline obesity.
  
  

• General assessment: Hydration appears adequate. The patient is alert and oriented, with no signs of lethargy, confusion, or deep breathing.

Diagnostic Evaluation

Management

The patient expresses strong motivation to reintegrate lifestyle measures to improve glycemic control and actively pursue weight reduction. In Switzerland, mandatory health insurance covers the cost of the above suggested therapy in the present clinical constellation. After appropriate instruction, self-administration of a GLP-1 receptor agonist appears feasible and acceptable to him. There is no history of gallbladder disease, diabetic retinopathy, or pancreatitis.

References

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