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43-year old patient presents to your clinic for an appointment. She has mild hypertension, which is currently well controlled with a ß-blocker. She was diagnosed with type 2 diabetes 6-years ago, and has been taking metformin and glipizide. She has noticed that her recent self-blood glucose monitoring numbers have been creeping up and with a most recent FPG of 160 mg/dl. At today’s visit, she has an A1C 8.0%. She tells you that until now her job has required she travel several times a month. This week she was promoted to a managerial position that does not require travel. Which of the following approaches would be the best for her?
Usually, the addition of basal insulin is considered the optimal initial insulin regimen; usually in conjunction with one or two noninsulin agents. Generally, therapeutic regimens should begin with some basal insulin before moving to more complex insulin strategies. Starting a pre-mixed insulin regimen as the initial insulin strategy can be considered in patients willing to take more than one injection a day and with higher A1C level (>9.0%). Pre-mixed regimens tend to lower A1C slightly more when compared to basal insulin alone. However, the use of pre-mixed insulin can lead to slightly more hypoglycemia and weight gain than basal insulin. When basal insulin is used, the continued use of secretagogues may provide some benefit in reducing initial glycemic control deterioration. However, with the addition of prandial insulin, while metformin is usually continued and may help prevent some weight gain, secretagogues should be stopped.. In addition to continued general diabetes education (SBGM, lifestyle modifications, disease course), patients should receive education on the avoidance, recognition and treatment of hypoglycemia.
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.
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