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April 23, 2016

Apr 23, 2016

Mr. Huang is a 61-year-old Asian-American businessman who comes in to see you for a follow-up appointment. He was diagnosed with type 2 diabetes 4 years ago and has a long-standing history (15 years) of hypertension and hypercholesterolemia, which are currently well controlled. Current medications are metformin (1500 mg/day), lisinopril and simvastatin. He is overweight (BMI 29 kg/m2), but feels he has a healthy diet and gets out for a 25-30 minute walk 3 or 4 times per week. He feels great, but over the last nine months or so, he has noticed that his home average glucose levels are in the 180-198 mg/dL range. At today’s visit, his A1C is 8.3%.

Mr. Huang achieves good glycemic control with his lifestyle modifications, metformin and linaglipitin, and returns every 6 months for follow-up visits. Three years after initiating this treatment plan, he returns to your clinic for his 6-month check-up. When asked how his diabetes management is going at home, he shares that recently he has been “unable to really get out and get as much exercise as he know he should due to his creaky, old knees acting up.” His current office A1C is 8.8%. You discuss with him what the next management steps may be to achieve his individualized glycemic goal. What would your next medical management step be?


Answer: B. Add a long-acting insulin analogue

Moving to a 3-drug combination would be appropriate in this individual. The addition of a basal dose of a long-acting insulin analogue would be the most appropriate choice for this individual. Rapid-acting insulin analogues are used for daytime bolus dosing. Both the DPP-4 inhibitors and the GLP-1 agonist are based on the incretin system. When new agents are added, they should have complementary mechanisms of action. Once A1C?8.5%, it is unlikely that a noninsulin agent will be adequately effective at lowering blood glucose levels.


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.