Patient case studies

Three contrasting cases of obese patients with type 2 diabetes mellitus are presented, which illustrate the management difficulties faced by clinician s. The first raises the issue of when to commence an oral hypoglycaemic age nt in a newly diagnosed but asymptomatic obese patient; the second case add resses the problem of when to commence insulin in the face of continuing we ight gain and poor glycaemic control; the final case is an example of the v icious metabolic spiral which so many patients enter, with increasing body weight, poor diabetic control and associated comorbidities. The discussion that follows each case presentation recognises the considerable cardiovascu lar risk faced by such patients and provides guidance about possible manage ment pathways including adjunctive anti-obesity pharmacotherapy.