Diabetes and Hypertension in a Patient With Food Insecurity
A 61-year-old man with type 2 diabetes (A1c 10.2%), hypertension, and obesity attends a follow-up visit. His medications are metformin 1000 mg twice daily, glipizide 5 mg daily, lisinopril 20 mg daily, and atorvastatin 40 mg daily. BP is 158/94, BMI 34, eGFR 55, urine albumin-to-creatinine ratio 90 mg/g. He reports skipping meals and sometimes taking his medicines without food because he cannot afford both. He works irregular hours and has no reliable transportation. He says he feels fine and does not want more medicines.
1. How should the NP prioritize treatment changes given his finances and adherence barriers?
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The NP should address the most dangerous gaps first: uncontrolled diabetes with A1c 10.2%, uncontrolled hypertension, and albuminuria indicating kidney risk. However, adding medicines without addressing food insecurity and cost may worsen adherence and increase hypoglycemia risk, especially with glipizide. A reasonable approach: simplify the regimen, consider stopping or reducing glipizide because of meal skipping and hypoglycemia risk, and prioritize metformin and a renin-angiotensin system agent for kidney protection. Discuss SGLT2 inhibitors or GLP-1 receptor agonists for cardiorenal benefit, but check cost and coverage; if unaffordable, document and consider patient assistance programs. Titrate lisinopril with potassium and creatinine monitoring. Set realistic, shared goals rather than demanding perfection. Screen for food insecurity and connect him to resources. The judgment is to avoid intensifying a complex regimen that he cannot follow and instead reduce harm while improving access.
2. What monitoring and safety education are needed?
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Check renal function and potassium after lisinopril changes, and monitor A1c in 3 months. Review hypoglycemia symptoms and provide a plan, especially if glipizide continues. Teach sick-day rules and when to hold metformin during dehydration or contrast procedures. Provide a glucometer or confirm access, and review BP monitoring at home if possible. Discuss low-cost food choices and meal timing, and coordinate with a dietitian or community resource. Emphasize that feeling fine does not mean the conditions are controlled. Document the patient's goals and barriers. Follow-up should be sooner than usual, perhaps 4-6 weeks by phone or telehealth, to assess tolerability and access before the next in-person visit.
3. How should the NP coordinate care and address social determinants?
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The NP should use a team-based approach: social work for food and transportation resources, pharmacy for cost review and assistance programs, and community health workers for follow-up. Consider telehealth or phone visits to reduce travel burden, and consolidate lab draws. Ask about insurance coverage and prescription costs, and prescribe generic or lower-cost options where clinically appropriate. Coordinate with the patient's employer schedule and offer flexible appointment times. Document social determinants in the record and use them to shape the plan. The NP should also connect him to diabetes self-management education that is accessible remotely or locally. The key judgment is that medication intensification alone will fail without addressing food, transportation, and cost; care coordination is part of the treatment plan, not an optional extra.