In this seventh episode, Dr Tebelele and Dr Mashitisho explore the nuances of managing diabetes in special populations, focusing on patients with comorbid conditions such as cardiovascular and renal disease, as well as the elderly and pregnant women. The discussion highlights how physiological differences, organ impairment, and polypharmacy demand tailored therapeutic decisions that prioritise safety without compromising glycaemic control.

Through clinical examples, the presenters demonstrate how to navigate diabetes care in complex patients—balancing treatment goals, medication selection, and monitoring strategies. The episode equips clinicians to individualise therapy in alignment with patient needs, clinical guidelines, and real-world constraints in South African primary care.

1. Describe the key principles of managing diabetes in patients with cardiovascular, renal, or hepatic impairment.
2. Adjust glycaemic targets and therapy choices based on patient age, frailty, and comorbidity profile.
3. Recognise the unique management needs of pregnant women and older adults with diabetes.
4. Apply practical clinical reasoning to balance efficacy and safety when combining therapies.
5. Integrate multidisciplinary approaches for ongoing care in complex patient populations.

• Tailor diabetes management plans for patients with comorbid cardiovascular and renal conditions.
• Select appropriate drug classes and insulin types with reduced risk of hypoglycaemia.
• Modify treatment goals according to individual risk, life expectancy, and quality-of-life considerations.
• Collaborate effectively across care teams to coordinate treatment for vulnerable populations.
• Enhance patient education and self-management strategies for complex, high-risk cases.

• Cardiovascular disease: Diabetes doubles the risk; use of cardioprotective agents such as SGLT2 inhibitors and GLP-1 agonists, where feasible.
• Renal impairment: Importance of dose adjustment and avoidance of nephrotoxic drugs; individualised HbA1c targets.
• Elderly patients: Simplify regimens, avoid hypoglycaemia, prioritise safety and function over strict control.
• Pregnancy and gestational diabetes: Early screening, lifestyle modification, and insulin as the preferred agent when required.
• Medication review: Avoid polypharmacy and adverse drug interactions through coordinated multidisciplinary management.
• Clinical monitoring: Regular assessment of renal function, cardiovascular status, and weight to guide therapy.
• Local perspective: Adaptation of international standards to South African settings with resource and access limitations.