GP CCE Cases · metabolic-and-endocrine-health
Type 2 diabetes uncontrolled on metformin with heart failure — CCE clinical encounter
CCE-style clinical encounter: a 63-year-old man attends with HbA1c above target on metformin, newly revealed heart failure, and fears about 'needing needles'. The candidate must select therapy by comorbidity before HbA1c, initiate an SGLT2 inhibitor, and safety-net for hypoglycaemia and driving.
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Prompt
A 63-year-old retired bus driver with type 2 diabetes of 6 years attends for a routine review. Metformin 1000 mg twice daily; HbA1c has drifted to 61 mmol/mol (7.7%). He mentions new breathlessness climbing stairs — an echo last month showed left ventricular ejection fraction 38%. He dreads injections, drives daily, and lives alone.
Objectives
- Recognise that comorbidity — not the HbA1c number — dictates the next agent in type 2 diabetes. [1]
- Explain and initiate an SGLT2 inhibitor for heart failure with reduced ejection fraction, quoting the outcome evidence honestly. [2]
- Address injection fear without committing prematurely to insulin; explore oral escalation options. [1]
- Deliver the hypoglycaemia-and-driving script appropriate to an insulin-or-secretagogue future. [3]
- Safety-net for SGLT2-inhibitor adverse effects including euglycaemic ketoacidosis during illness. [1]
References4ShowHide
- [1]Davies MJ, Aroda VR, Collins BS, et al. Management of hyperglycemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association and the European Association for the Study of Diabetes Diabetologia, 2022.PMID 36151309
- [2]McMurray JJV, Solomon SD, Inzucchi SE, et al. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction N Engl J Med, 2019.PMID 31535829
- [3]Inkster B, Frier BM Diabetes and driving Diabetes Obes Metab, 2013.PMID 23350766
- [4]Li M, Liu J, Sun P, et al. Risk factors for hypoglycemia in patients with type 2 diabetes mellitus: a systematic review and meta-analysis Front Endocrinol (Lausanne), 2026.PMID 42620370