Diabetes results review — the rising HbA1c trend
PLAB 2 & PRES 3 · endocrine / data interpretation · medium · 10 minutes
Candidate brief
You are an FY2 doctor in a GP surgery. Mrs Fatima Hussain, 59, has type 2 diabetes and has come to discuss her latest results. Her HbA1c trend over 18 months is shown below, along with today's other results. HbA1c: 52 mmol/mol (18 months ago) → 58 → 64 → 71 mmol/mol (this week) Weight: 82 kg → 86 kg (BMI 31) BP today: 146/88 mmHg eGFR: 62 (stable); urine ACR: 38 mg/mmol (raised; <3 is normal) Total cholesterol: 5.4 mmol/L; HDL 1.1 Medicines: metformin 1 g twice daily, gliclazide 80 mg twice daily (max dose reached last time), ramipril 5 mg daily Her eye screening is overdue by a year. Please interpret the results and agree the next steps with her.
What examiners look for
A single HbA1c is a photograph; the trend is the film. 52 to 71 across eighteen months, through a maximal sulfonylurea dose, is the disease telling you the plan failed — slowly enough that every individual appointment looked like a small problem. Data stations are testing whether you read time, not values. Convert and contextualise: 71 mmol/mol is about 8.7%, and her target is 53 (7.0%) — not 48 — because she takes a hypoglycaemia-causing drug. Examiners listen for the right target for THIS patient, and patients engage when the number is translated into the units their family uses. The quiet results treat the patient too: albuminuria with a "stable" eGFR is early kidney disease announcing itself in the urine, and it should steer therapy (an SGLT2 inhibitor's kidney protection, BP ambition) more than the glucose does. The missing statin and the missed eye screen are findings, not admin. Adherence is history-taking, not surveillance. "How does it go with the tablets, honestly?" found the missed doses, the Ramadan improvisation and the hypo fear in one question — and changed the prescription more than any single drug choice in the plan. Patients lie to doctors who lecture; they tell the truth to doctors who normalise. Insulin is a treatment, never a threat. The moment it is used as a punishment for a rising trend, the patient stops reporting honestly — and a woman whose mother dialysed deserves a plan built around protecting her kidneys, which today means an SGLT2 inhibitor, a statin, blood-pressure control and a three-month leash, agreed with her rather than announced at her.
Guideline references
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