A 63-year-old man comes to the physician because of high blood glucose levels on home monitoring. His medical problems include type 2 diabetes mellitus, hypertension, hyperlipidemia, obstructive sleep apnea, and obesity. His current medications include metformin, glyburide, hydrochlorothiazide, amlodipine, lisinopril, simvastatin, and aspirin. He was diagnosed with type 2 diabetes 14 years ago, and he has been non-compliant with his diet and exercise plan. He uses CPAP every night.
For the last few weeks, his fasting glucose levels on home monitoring averaged around 250 mg/dL. He complains of excessive urination and a 6 lb (2.7 kg) weight loss over the last few months. He seems to be motivated to do whatever it takes to decrease his blood glucose levels.
His blood pressure is 130/80 mm Hg, pulse is 92/min, and respirations are 16/min. The patient's body mass index is 30 kg/m². The remainder of the physical examination is within normal limits, except for trace pitting edema to his ankles bilaterally.

In addition to implementing rigorous lifestyle changes, which of the following is the most appropriate treatment modification?

Question

A 63-year-old man comes to the physician because of high blood glucose levels on home monitoring. His medical problems include type 2 diabetes mellitus, hypertension, hyperlipidemia, obstructive sleep apnea, and obesity. His current medications include metformin, glyburide, hydrochlorothiazide, amlodipine, lisinopril, simvastatin, and aspirin. He was diagnosed with type 2 diabetes 14 years ago, and he has been non-compliant with his diet and exercise plan. He uses CPAP every night.
For the last few weeks, his fasting glucose levels on home monitoring averaged around 250 mg/dL. He complains of excessive urination and a 6 lb (2.7 kg) weight loss over the last few months. He seems to be motivated to do whatever it takes to decrease his blood glucose levels.
His blood pressure is 130/80 mm Hg, pulse is 92/min, and respirations are 16/min. The patient's body mass index is 30 kg/m². The remainder of the physical examination is within normal limits, except for trace pitting edema to his ankles bilaterally.

In addition to implementing rigorous lifestyle changes, which of the following is the most appropriate treatment modification?

Quizplus · Accepted Answer

11ec193a_97b1_c475_853d_9f129ccade8c_MD0002_00 This patient with poor diabetes control (e.g., osmotic symptoms, elevated A1C) would benefit most from intensive insulin therapy. Most patients diagnosed with type 2 diabetes mellitus have lost approximately 50% of their insulin secretory capacity at the time of diagnosis, and progressive pancreatic beta cell dysfunction causes a shift from normoglycemia with insulin resistance to overt hyperglycemia. As a result, oral anti-diabetic agents alone cannot maintain normoglycemia over time. Patients with mild to moderate A1C elevation (generally 7.5-10.0%) may be started on one injection of bedtime basal insulin in addition to their oral antidiabetic agents. The basal insulin dose is gradually increased to decrease the fasting glucose levels to the target range. Patients who do not meet their goal A1C may require prandial boluses with short acting insulin. This patient has a very high A1C and osmotic symptoms, and adding basal insulin alone is unlikely to bring his A1C to target levels (Choice C). He likely has low insulin secretion and needs both basal and prandial insulin (basal-bolus therapy) for optimal diabetes control. Sulfonylureas and other insulin secretagogues (e.g., meglitinide) are discontinued when a basal-bolus regimen is started because their use is redundant. Combined use of insulin and sulfonylureas may lead to higher insulin levels, more weight gain, and higher risk of hypoglycemia. (Choice A) Although insulin secretagogues (e.g., sulfonylureas) are discontinued when an intensive insulin regimen is begun, metformin is generally continued. Metformin inhibits hepatic glucose production with a possible synergistic effect with basal insulin, and the combination usually causes less weight gain. (Choice D) Liraglutide is a glucagon-like peptide-1 (GLP-1) analogue that lowers the A1C by 0.5-1% and would not be as effective in this patient. (Choice E) Patients with suboptimal glycemic control on two oral agents may be given a third oral agent if they refuse to start insulin and have an A1C just above 7%. However, patients with a high A1C (such as this patient) on two oral diabetic agents usually require insulin and do not benefit from a third oral agent. Educational objective: Basal insulin is a safe, simple, and effective way to initiate insulin in patients with type 2 diabetes mellitus who fail one or more oral agents. Intensive insulin therapy (basal-bolus) is considered for very high A1C with symptomatic hyperglycemia. Insulin secretagogues are discontinued when intensive insulin therapy is begun, while metformin is usually continued. __________ References: The treat-to-target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. (http://www.ncbi.nlm.nih.gov/pubmed/14578243) Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. (http://www.ncbi.nlm.nih.gov/pubmed/18945920)

A 63-Year-Old Man Comes to the Physician Because of High