Dilemmas in diagnosing and managing of type 2 diabetes

Case history 1 – The thin person with type 2 diabetes

The problem

Karen was 41 years old and working as a travel agent. She was diagnosed with type 2 diabetes four years previously and her maintenance treatments were metformin 1g bd and atorvastatin 20 mg od for cardiovascular protection. There was no family history of diabetes. Karen was up to date with her screening appointments and there were no ongoing diabetes complications.

A blood test ahead of her diabetes review appointment in primary care revealed a marked deterioration in glycaemic control from an HbA1C of 57 mmol/mol six months previously to 85 mmol/mol. Renal function tests were satisfactory with an eGFR of 74 ml/min/1.73m2. Liver and thyroid function tests were normal and lipid profile favourable with a total cholesterol of 3.7 mmol/L and a non-HDL cholesterol of 2.3 mmol/L.