From bio-psycho-social points of view, diabetes has become crucial problem worldwide [1]. Each country in several regions has managed diabetic matters for long, such as European and North American [2,3]. American Diabetes Association (ADA) has announced the latest guideline for managing type 2 diabetes (T2D) in Jan 2024 [3]. Recent topics include some types of novel oral hypoglycemic agents (OHAs) beneficial for actual practice. Among them, imeglimin (Twymeeg) has been introduced with pharmacological function mechanism through mitochondria pathway [4]. Authors’ et al have presented some reports of T2D patients with clinical efficacy by imeglimin [5].

For T2D, basic principle for treatment includes nutritional therapy, exercise continuation and medicine of OHA or insulin. As diet method, calorie restriction (CR) was formerly usual measure, but low carbohydrate diet (LCD) has been recently known with clinical efficacy for T2D [5]. LCD was started in medical care and health care regions, where two doctors of Atkins and Bernstein have contributed much through educational books [6,7]. Successively, LCD was also initiated in Japan, in which author’s collaborators have developed social movement of LCD via Japan LCD promotion Association (JLCDPA) [8,9]. Our team has continued actual LCD prevalence more by seminars, books and various presentations [10]. We have recommended three types of useful LCD meals. They are petite LCD, standard LCD and super LCD that include carbo amount ratio by calorie calculation as 40%, 26% and 12%, respectively [11].

As we have continued diabetic practice and research for various types of patients, a meaningful T2D male case was present. He has suffered from T2D and diabetic macroangiopathy for long, and showed remarkable clinical effect by imeglimin (Twymeeg) associated with HbA1c decrease. Furthermore, he showed parallel improvement of HbA1c decrease and improved arteriosclerosis in his clinical progress. His general outlines and related clinical perspectives would be described in this article.

Presentation of Cases

Medical history

The patient is 68-year-old male with T2D. He has past history of several clinical problems. He was diagnosed as T2D in early 50s, dyslipidemia of elevated LDL and benign prostate hyperplasia (BPH) in later 50s, and peripheral artery disease (PAD) and coronary heart disease (CHD) in early 60s. Furthermore, he was pointed out to have nephropathy in late 60s.

Clinical changes in HbA1c were shown in Figure 1. He has been treated by T2D and glucose variability has been unstable for years. Authors and collaborators have managed his total therapeutic measures, including adequate nutritional therapy of low carbohydrate diet (LCD), stable exercise daily habit, and administration of oral hypoglycemic agents (OHAs). In response to these combined therapy, HbA1c value in 2018 was gradually decreased from 8.0% to 5.7% for a year. His diabetic situation had been satisfactory stable during 2019 and 2020 as keeping low HbA1c value for 5.7%-6.6%. From spring 2021, his HbA1c was gradually elevated, and then OHA was changed from pioglitazone to empagliflozin in summer 2021. After that, HbA1c was peaked to 7.5% in April 2023. Consequently, imeglimin (Twymeeg) was started and then HbA1c was decreased to 6.2% for 5 months. His diabetic status has been now kept stable so far.

Physicals and laboratory exams

The physical examination in March 2023 revealed in the following: consciousness, speech and vital signs were in the normal ranges. No remarkable changes were observed in the lung, heart, abdomen, extremities or neurological exams. He did not complain of specific symptoms or signs. His physique showed height 162.0 cm, weight 61.3 kg and BMI 23.4 kg/m².