A 50-year-old woman comes to the physician for follow-up of type 2 diabetes mellitus. She was diagnosed with diabetes 2 years ago and tried lifestyle modifications. She currently takes metformin 1000 mg twice daily. The patient has a family history of diabetes, chronic kidney disease, and stroke. She does not use tobacco, alcohol, or illicit drugs.
Her blood pressure is 152/92 mm Hg and pulse is 88/min. Her BMI is 39 kg/m². Acanthosis nigricans is present on the neck and axilla. The liver span is 10 cm. Peripheral pulses are 2+ bilaterally. There is no sensory loss over the lower extremities as assessed by microfilament test.
Laboratory results are as follows:

Urine is positive for microalbumin.
Which of the following measures is most likely to achieve a hemoglobin A1c <6.0% in one year in this patient?

Question

A 50-year-old woman comes to the physician for follow-up of type 2 diabetes mellitus. She was diagnosed with diabetes 2 years ago and tried lifestyle modifications. She currently takes metformin 1000 mg twice daily. The patient has a family history of diabetes, chronic kidney disease, and stroke. She does not use tobacco, alcohol, or illicit drugs.
Her blood pressure is 152/92 mm Hg and pulse is 88/min. Her BMI is 39 kg/m². Acanthosis nigricans is present on the neck and axilla. The liver span is 10 cm. Peripheral pulses are 2+ bilaterally. There is no sensory loss over the lower extremities as assessed by microfilament test.
Laboratory results are as follows:

Urine is positive for microalbumin.
Which of the following measures is most likely to achieve a hemoglobin A1c <6.0% in one year in this patient?

Quizplus · Accepted Answer

This patient has uncontrolled diabetes, hyperlipidemia, hypertension, and severe obesity, and would likely benefit the most from bariatric surgery. Candidates for bariatric surgery include patients with a BMI >40 kg/m² without comorbid illness or a BMI of 35-40 kg/m² with >1 comorbid illness (eg, type 2 diabetes mellitus, hyperlipidemia, hypertension). ² ² Randomized controlled trials have shown that Roux-en-Y gastric bypass is more effective than conventional medical therapy (eg, lifestyle changes, weight management counseling, oral hypoglycemics, insulin) in patients with uncontrolled type 2 diabetes and severe obesity (BMI >35). In one study, 42% of patients achieved a hemoglobin A1c <6.0% at 12 months with combined medical therapy and Roux-en-Y gastric bypass, versus 12% of patients who received intensive medical therapy alone. In another study, 75% of patients who underwent Roux-en-Y gastric bypass alone achieved a hemoglobin A1c <7% at 12 months, versus 32% of patients who received intensive medical therapy alone. < Other bariatric surgical procedures (eg, sleeve gastrectomy, adjustable gastric band) have also demonstrated improvement or remission in obese patients with type II diabetes. (Choices A, B, D, and E) Intensive nutritional counseling and/or medications (eg, sulfonylureas, incretin mimetics, insulin) are less likely to achieve diabetic remission in this patient compared to bariatric surgery. medications Educational objective: Severely obese patients with type 2 diabetes have a higher likelihood of achieving diabetic remission with bariatric surgery compared to conventional medical therapy. __________ References: Bariatric surgery versus conventional medical therapy for type 2 diabetes. (http://www.ncbi.nlm.nih.gov/pubmed/22449317) Bariatric surgery versus intensive medical therapy in obese patients with diabetes (http://www.ncbi.nlm.nih.gov/pubmed/22449319)

A 50-Year-Old Woman Comes to the Physician for Follow-Up of Type