Type 2 diabetes — KFP-style written assessment

KFP 1 (10 marks)

A 57-year-old man with BMI 32 kg/m² and hypertension was found on two occasions to have HbA1c 55 mmol/mol (7.2%) and fasting glucose 7.8 mmol/L. He is asymptomatic, walks daily, and asks whether he can "just watch his diet". His father lost a leg to diabetes. ^[1]

1. Confirm or refute the diagnosis with the criteria you would apply, and state what his single-test status would have required had only one result been abnormal. (3) ^[1]
2. Justify starting metformin now rather than diet alone, citing the specific trial evidence. (4) ^[2]
3. Outline the annual complication surveillance you will schedule from today. (3) ^[3]

Model answers

1. The diagnosis is confirmed: HbA1c 55 mmol/mol exceeds the 48 mmol/mol (6.5%) threshold and fasting glucose 7.8 mmol/L exceeds 7.0 mmol/L — two abnormal results from the same or separate samples suffice in an asymptomatic patient. Had only one test been abnormal, confirmation with a second abnormal result (repeat HbA1c, fasting glucose or OGTT) would be required before labelling. ^[1]
2. UKPDS 34 randomised overweight patients with newly diagnosed type 2 diabetes to metformin or conventional diet therapy over a median 10.7 years: metformin reduced any diabetes-related endpoint by 32% (95% CI 13–47), diabetes-related death by 42%, and all-cause mortality by 36% — benefits diet alone did not deliver. His family history of diabetic complications strengthens the case for immediate pharmacotherapy alongside lifestyle change. ^[2]
3. Annual cycle: dilated retinal photography; urine albumin-to-creatinine ratio and eGFR; foot examination with 10 g monofilament and pulse assessment; blood pressure, lipids, weight and smoking review; influenza and pneumococcal vaccination status; and structured hypoglycaemia/driving advice whenever regimens change. ^[3]