Patient profile: Female, 67 years old.

Presentation: The patient had lived with Type 2 diabetes for 12 years. Her HbA1c was 8.9% while taking metformin and a sulfonylurea. She also had neuropathic pain, stage 3 CKD with eGFR 45, and was already taking a statin.

Assessment: The review included medication safety, hypoglycaemia risk, foot examination, microalbuminuria, retinal screening status, B12 level, renal and liver function, and neuropathy scoring. Medication optimisation was also considered.

Clinical picture: This was complex, long-standing diabetes with complications, raised cardiovascular risk and a medication regime that increased hypoglycaemia risk.

Support plan: The patient’s care was reviewed with endocrinology. Options included replacing sulfonylurea with a GLP-1 receptor agonist and considering an SGLT2 inhibitor if renal criteria allowed. Nutrition focused on a portion-controlled Mediterranean plate with low-glycaemic carbohydrates and adequate protein to reduce sarcopenia risk. Neuropathy support included alpha-lipoic acid 600 mg daily, B-complex and B12 if deficiency was present, topical support where appropriate, and referral for podiatry. Cardiometabolic risk reduction focused on blood pressure, lipid optimisation and smoking cessation if relevant. Supervised exercise, weight management and sleep support were also included.

Outcome at 12 months: HbA1c reduced from 8.9% to 7.2%. Neuropathy pain improved partially, renal function stabilised and albuminuria reduced. Weight reduced modestly by 4 to 5%. The patient also reported better daily function and fewer hypoglycaemic episodes.

Key point: In established diabetes, safe medication review and complication management are just as important as lifestyle change.