Sunday , July 22 2018

Question 835

May 28, 2016

Mr. Fontello is an overweight, Caucasian 63-year-old patient who comes in for a 6-month check-up. He has a 12-year history of type 2 diabetes. He was diagnosed at age 33 with high blood pressure, but had never really done much about it as it was “too much of a hassle” and he felt “just fine.” At the time his diabetes was diagnosed, he was referred to a diabetes education program and was started on metformin, lovastatin, losartan and aspirin. He has an individualized A1C goal of 7%. Four years after diagnosis, pioglitazone was added to Mr. Fontello’s diabetes regimen. Three years ago, he came in for an appointment complaining of polyuria, polydipsia and fatigue with an office A1C of 9.3%. At that time, he was started nightly on basal insulin detemir. Since that time, he has made concerted efforts to eat a healthy diet and get to the gym. Today, he reports his SBGM fasting plasma glucose levels are on target (FPG<130mg/dL). He also states that his feet always feel a little bit swollen. BP 128/78, HR 73, RR 19. Physical exam is remarkable for peripheral edema and mildly decreased pedal pulses. Current medications: metformin, pioglitazone, insulin detemir, lovastatin, losartan, aspirin. At today’s visit, his office A1C is 8.1%. What changes would you recommend for his antihyperglycemic regimen?


Answer:  D. Add a rapid-acting insulin analogue to his largest meal of the day.

When FPG is at target, but postprandial glucose levels are above target (generally reflected in an A1C higher than target), consideration should be given to the addition of a preprandial insulin dose to the management plan. This can be achieved through either (a) addition of premixed insulin before the morning and evening meals (titrated to the correct dose), or (b) the titrated and graduated addition of rapid-acting insulin bolus dose to meals, starting with the largest meal (highest carbohydrate content) of the day, followed by the next largest meal and finally the smallest meal, based upon individualized glycemic goals. Increasing his detemir dose would not achieve the goal of blunting daytime postprandial glucose elevations and could lead to an increased risk of hypoglycemia. Adding glyburide at this point would not be a realistic option, as secretagogues do not seem to provide any additional benefit once insulin has been started.


Inzucchi S, et al. Management of hyperglycemia in type 2 diabetes: A patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012; 35(6):1364-1379.