A 62-year-old man comes to the office to follow-up diabetes. He was diagnosed with type 2 diabetes mellitus 12 years ago and is being treated with sitagliptin and metformin. The patient's father also had type 2 diabetes and died of a "massive heart attack" at age 67. He states, "My father refused to take insulin despite very high sugar levels. I do not want to be like him." The patient has good compliance with his medication regimen as well as with dietary and exercise recommendations. However, his home finger-stick blood glucose levels are frequently 250-300 mg/dL. The patient feels tired during the day as his sleep is interrupted by frequent urination, and he is often bothered by a pins-and-needles sensation in his feet when trying to sleep. He has lost significant weight since his last visit, which he attributes to rigorous lifestyle changes. Medical history is notable for obesity, gout, hypertension, and hyperlipidemia. The patient's other medications include atorvastatin, low-dose aspirin, lisinopril, and amlodipine. He quit smoking 30 years ago and does not use alcohol or illicit drugs. Blood pressure is 134/80 mm Hg and pulse is 70/min. BMI is 33 kg/m². Examination of the feet is notable for a bilateral decrease in sensation on monofilament testing. The remainder of the physical examination is unremarkable. Hemoglobin A1c is 9.5% and serum creatinine is 1.4 mg/dL. The patient is counseled on the possibility of starting a long-acting basal insulin analog. Which of the following is an advantage of using this therapy over NPH for this patient?

Question

A 62-year-old man comes to the office to follow-up diabetes. He was diagnosed with type 2 diabetes mellitus 12 years ago and is being treated with sitagliptin and metformin. The patient's father also had type 2 diabetes and died of a "massive heart attack" at age 67. He states, "My father refused to take insulin despite very high sugar levels. I do not want to be like him." The patient has good compliance with his medication regimen as well as with dietary and exercise recommendations. However, his home finger-stick blood glucose levels are frequently >250-300 mg/dL. The patient feels tired during the day as his sleep is interrupted by frequent urination, and he is often bothered by a pins-and-needles sensation in his feet when trying to sleep. He has lost significant weight since his last visit, which he attributes to rigorous lifestyle changes. Medical history is notable for obesity, gout, hypertension, and hyperlipidemia. The patient's other medications include atorvastatin, low-dose aspirin, lisinopril, and amlodipine. He quit smoking 30 years ago and does not use alcohol or illicit drugs. Blood pressure is 134/80 mm Hg and pulse is 70/min. BMI is 33 kg/m². Examination of the feet is notable for a bilateral decrease in sensation on monofilament testing. The remainder of the physical examination is unremarkable. Hemoglobin A1c is 9.5% and serum creatinine is 1.4 mg/dL. The patient is counseled on the possibility of starting a long-acting basal insulin analog. Which of the following is an advantage of using this therapy over NPH for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c133_cad8_8f63_2d2def27cf1a_MD0005_00 This patient with long-standing type 2 diabetes mellitus (T2DM) has suboptimal glycemic control despite 2 oral agents and appropriate lifestyle changes. T2DM is characterized by insulin resistance, in addition to a progressive decline in pancreatic beta-cell function over time. As insulin production falls, advancement of the patient's antidiabetic regimen is required to maintain glycemic control. Insulin therapy is recommended for patients with T2DM who have a hemoglobin A1c >9%, especially if associated with symptoms of hyperglycemia (eg, nocturia, as in this patient). When insulin therapy is necessary, basal insulin (ie, insulin that is intended to work continuously throughout the day) is typically added first and is safe to use with other antidiabetic agents. Both NPH and long-acting insulin analogs (eg, detemir, glargine, degludec) are effective in lowering A1c in patients with T2DM. However, NPH is associated with a higher risk of hypoglycemia compared with long-acting insulin analogs. (Choices A and D) Good glycemic control, regardless of the type of therapy, has been shown to decrease the risk of microvascular complications (ie, retinopathy, nephropathy, neuropathy). Conversely, there is currently no conclusive evidence that glycemic control with insulin reduces the risk of macrovascular events (eg, myocardial infarction, stroke) or all-cause mortality. (Choice B) Local injection site reactions are comparable with all insulin preparations. (Choice C) Although generic formulations of long-acting insulin analogs are now available, their cost is still significantly higher than that of NPH. Educational objective: Both NPH and long-acting insulin analogs (eg, detemir, glargine, degludec) are effective in lowering hemoglobin A1c in patients with type 2 diabetes mellitus. However, NPH is associated with a higher risk of hypoglycemia compared with long-acting insulin analogs. References: Pharmacologic therapy for type 2 diabetes: synopsis of the 2017 American Diabetes Association standards of medical care in diabetes. (http://www.ncbi.nlm.nih.gov/pubmed/28288484) Patient-level meta-analysis of efficacy and hypoglycaemia in people with type 2 diabetes initiating insulin glargine 100U/mL or neutral protamine Hagedorn insulin analysed according to concomitant oral antidiabetes therapy. (http://www.ncbi.nlm.nih.gov/pubmed/28092788)

A 62-Year-Old Man Comes to the Office to Follow-Up Diabetes