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Intentional weight loss by patients with diabetes and obesity improves their glycaemic control, and reduces their morbidity and mortality. Usually, this is difficult to achieve, as long-term dietary adherence is low and many hypoglycaemic drugs promote weight gain. Both metformin and rimonabant can promote weight loss, and this case illustrates the effectiveness of these medications in combination.A 59-year-old male with morbid obesity (body mass index [BMI] 46) presented with a five-week history of hyperglycaemic symptoms and recent weight loss. He had ketonuria 3+, serum glucose 16.8mmol/L, HCO3 24mmol/L and pH 7.46. A diagnosis of type 2 diabetes associated with morbid obesity presenting with ketosis was made.After inpatient treatment with twice-daily subcutaneous (SC) mixed insulin, he was discharged home on insulin glargine 40 units daily SC, rimonabant 20mg o.d. and metformin sustained release titrating up to 2g o.d. He was given standard dietetic weight-reducing and exercise advice. Over the next 13 months, he gradually lost 21kg in weight, from 141kg at discharge to 120kg (BMI 39.2). His insulin glargine dose was reduced progressively and stopped. His HbA1c was then 5.2% with self-monitored glucose levels <7mmol/L.This case illustrates that combined therapy with rimonabant and metformin in a newly presenting obese ketosis-prone, insulin-treated patient may produce highly significant weight loss and the successful progressive withdrawal of insulin while achieving tight blood glucose control. Copyright © 2008 John Wiley & Sons.