The first step is to eliminate the factors that are aggravating his
diabetes. The cranberry juice should be stopped if he will agree and the glyburide,
which is associated with weight gain, should be switched to metformin, which
is not.12 Ramipril, an angiotensin-converting
enzyme inhibitor that reduces cardiovascular risk and incipient nephropathy,
and also lowers blood pressure and blood glucose,13 should
be substituted for the thiazide diuretic, which can increase insulin resistance.
As a matter of priority, diet, exercise, and smoking cessation can be deferred
until the blood glucose is brought under control. Managing the dyslipidemia
may also be deferred for now; the lipids may come under control as the blood
glucose improves. Finally, the patient's blood glucose meter should be replaced.
Because so many changes are being made to the patient's regimen, written instructions
of what to start and what to stop should be provided. The patient should be
requested to take all medications as prescribed, to the best of his ability,
during the next 2 weeks, and a follow-up visit should be scheduled at that
time for a review and reassessment.