The management of most chronic diseases involves prescribing issues. Many practices have stepwise protocols to ensure treatment of chronic diseases is optimised. Practice protocols should use current best evidence or national guidelines (e.g. NICE, BTS guidelines). You may wish to use this exercise to demonstrate the management of a patient over a period of time using such a protocol/guideline. Template available here.


Patient history:

64 year old male


2006 – presented with thirst and polyuria type 11 diabetes diagnosed initial fasting glucose 9.2. Advised re diet exercise and weight loss. Initially does well with glycaemia controlled on no medication.


2009 – regular monitoring reveals worsening control with a HBa1c of 8.9%. Metformin started as BMI 32, hypertensive with no end organ damage, Ramipril started U+E checked normal.


2010 – Metformin dose increased in attempt to improve control – simvastatin commenced as cholesterol 6.1 mm/l and has hypertension and cardiovascular risk now > 20% using JBS tool. Later in the year gliclazide commenced initial glycaemic control excellent.


2013 Now taking maximum doses of metformin and gliclazide control sub optimal – possible referral for consideration of GLP-1 Analogue or insulin therapy, but feel a trial of a Gliptin worth a go and agreed with patient. Blood pressure increased and microalbuminuria just started, optimise Ramipril and start Aspirin as a primary prevention. Simvastatin optimised – total cholesterol now 3.9 mm/l


2014 Well established on triple therapy. Improvement in glycaemic control – no change in management plan but if HbA1c worsens, will need to consider referral as not yet initiating GLP-1 analogues or insulin in practice and growing evidence against starting a glitazone though would discuss this further with patient. Also, though no direct experience as yet, could consider newer dapagliflozin drug provided eGFR remains good 

Please indicate the guideline / protocol used and where the management of this patient follows the document and any variation away from it if appropriate

I believe that the management of this patient is sound and evidence based. The use of a gliptin is in accordance with NICE guidelines and the protective medications are appropriate


  • ACE inhibitor for hypertension appropriate first line treatment in a relatively young patient
  • Aspirin indicated due to the raised cardiovascular risk (hypertension, microalbuminuria plus diabetes)
  • Statin therapy for those aged > 40 years when cardiovascular risk reached 20% or more.


The patient probably warranted aspirin and simvastatin earlier but it seems now that this treatment is optimal.