[Expert Solution]: It has been 6 months since MW’s last DEC visit

It has been 6 months since MW’s last DEC visit. He has been taking 3 medications for his diabetes, at full dose as prescribed. metformin 1000mg BID gliclazide 80 mg 2 tabs bid empagliflozin 25mg daily He has a prescription for basal insulin (10units glargine 100 units/mL) but has not started to take this. His weight has decreased 10 lbs and MW’s recent bloodwork shows an improvement of his A1C to 7.9%. He has occasional mild/moderate hypoglycemia which he treats appropriately. He does express concern that his fasting capillary blood glucose readings are often 9-10mmol/L. This is frustrating as he states, “I am eating less, walking 5 days a week and taking all those medications. What is the point?! I also have diarrhea since starting all these medications.” How would you approach/respond to his frustration? “It appears he is overwhelmed at this visit. I won’t review hypoglycemia as he treats appropriately.” What is your thought about this statement? Is an A1C of 7.9% of concern? If yes, why? If not, why not? Logbook follows: mmol/L 7am (ac breakfast) 12 noon (ac lunch) 6pm (ac supper) Before bed No snack Day 1 10.3 3.8 12.1 7.3 Day2 11.4 5.0 9.8 10.4 Day 3 7.6 6.0 10.2 6.3 Day 4 9.3 4.0 7.9 7.2 Day 5 10.2 3.7 8.4 5.9 Assuming Mr. MW agrees to start basal insulin, how should/could this be increased? What about the other medications for diabetes that he is taking? Would you continue or discontinue? Why? Please be specific about the medications. What type of insulin delivery device would you recommend and what length of needle tip? What options are available to him? What about a pump? After 2 months of taking insulin once a day, Mr. MW’s glucose levels at breakfast are at target but the glucose levels are rising throughout the day. What is the next step regarding his medications? What type of glucose monitoring system might be suggested? How would you explain this progression to Mr. MW? Mr. MW has twice yearly diabetes centre visits. Lab work is ordered ahead of these visits. Which routine lab tests should be ordered? What are the recommended target values? What other screening tests for complications are recommended? After a few years with diabetes, what do you expect Mr. MW’s medication and/or insulin regimen to look like? He now has established cardiovascular disease and chronic kidney disease. Would he still be on multiple diabetes medications? Which factors would influence the decision about keeping or discontinuing antihyperglycemic agents?