A 45-year-old man comes to the office for follow up of type 2 diabetes mellitus. Since his diagnosis 4 years ago, the patient has followed a low-fat diet and taken metformin and atorvastatin as prescribed. Ophthalmologic examination conducted a month ago revealed no evidence of diabetic retinopathy. Blood pressure is 119/76 mm Hg, pulse is 70/min, and BMI is 30 kg/m². Heart rhythm is regular and without murmurs. Lungs sounds are normal. Foot examination shows normal pulses and intact sensation to vibration, pressure, and pinprick. Hemoglobin A1c is 7.0%, creatinine is 0.9 mg/dL, and urine albumin/creatinine ratio is 15 mg/g. What is the most appropriate next step in management of this patient?

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Explanation: 11ec25c8_d255_5fe7_bc81_e14a89373fad_MD0003_00 Routine health maintenance is a mainstay of preventive therapy in type 2 diabetes because it can reduce the risk of microvascular (eg, retinopathy, neuropathy, nephropathy) complications and improve cardiovascular risk factors (eg, weight, blood pressure, dyslipidemia). Key components include: lifestyle changes (diet, exercise, smoking cessation, weight management). glycemic control (goal A1c ≤7.0%; higher for older adults and those with multiple comorbidities). screening for and control of cardiovascular risk factors (eg, hypertension [goal: <130/80 mm Hg], obesity, cholesterol). regular screening and treatment for albuminuria (via annual urine albumin/creatinine ratio testing [normal: <30 mg/g]), foot neuropathy, and retinopathy. This patient has made appropriate lifestyle changes; has no diabetic neuropathy or retinopathy; and has a hemoglobin A1c at goal, a blood pressure below goal, and a urine albumin/creatinine ratio within normal limits. No additional medication is indicated at this time. By contrast, in patients with moderately increased albuminuria (albumin/creatinine ratio of 30-300 mg/g) and hypertension, ACE inhibitors (ACEIs) (eg, lisinopril) or angiotensin II receptor blockers (ARBs) are indicated for secondary prevention of diabetic nephropathy as they reduce progression to overt nephropathy and kidney failure. These effects are not proven in patients who are normotensive and have normal albumin excretion (<30 mg/g); in these patients, ARBs and ACEIs may increase cardiovascular mortality risk, and medication risks (eg, hypotension, hyperkalemia, severe glomerular filtration rate reduction) outweigh benefits (Choice C). (Choice A) Clopidogrel is used in secondary prevention of recurrent ischemic stroke. For certain patients with diabetes (>10% 10-year stroke risk), primary stroke prevention with daily low-dose aspirin (not clopidogrel) can be considered. (Choice B) Glyburide is used as therapy in certain patients with diabetes and persistent hyperglycemia (eg, A1c >7.0% despite lifestyle changes and metformin). This patient's A1c is already well controlled; no additional agents are needed. (Choice D) Certain beta blockers such as metoprolol can improve symptoms and survival and hospitalization rates in patients with heart failure and reduced ejection fraction. Beta-blocker therapy is not indicated in this patient. Educational objective: Patients with type 2 diabetes should be screened annually for moderately increased albuminuria. Patients with hypertension and moderately increased albuminuria should be treated with ACE inhibitors (ACEIs) for secondary prevention of overt nephropathy. However, ACEIs are not indicated for primary prevention in patients with diabetes who are normotensive and have normal albumin excretion. References: Effect of candesartan on microalbuminuria and albumin excretion rate in diabetes: three randomized trials. (http://www.ncbi.nlm.nih.gov/pubmed/19451554) Renal and retinal effects of enalapril and losartan in Type 1 diabetes. (http://www.ncbi.nlm.nih.gov/pubmed/19571282) Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systemic review and meta-analyses. (http://www.ncbi.nlm.nih.gov/pubmed/26920333)

A 45-Year-Old Man Comes to the Office for Follow Up