Test Your Knowledge #527: An African-American Man with Type 2 Diabetes and Obesity, Part Two of Three

• Diagnosis 5 years ago, with an A1C of 6.7%
  • Initially able to control his diabetes with exercise and improvement to his diet
• A1C of 7.8% 2 years following diagnosis
  • Started on glipizide ER, 5 mg daily
  • Glipizide ER increased 3 months later to 10 mg daily
• A1C of 8.4% 2 years later (4 years following diagnosis) with weight gain of 15 pounds
  • Metformin added to glipizide ER regimen, started at 500 mg to minimize gastrointestinal (GI) effects
  • Metformin titrated up to 1000 mg twice daily

Mr. Barton has now been on the glipizide ER plus metformin regimen for 1 year. 

In addition to diabetes, he has a 20-year history of dyslipidemia and an 18-year history of hypertension.

Mr. Barton works as a high school physics teacher and is married with 2 grown children. His father had Type 2 diabetes and died of cardiovascular disease (CVD) at age 58; his mother is currently treated for hypertension but is otherwise healthy. When Mr. Barton was first diagnosed, he played golf regularly. He was forced to stop due to chronic back pain, and has not found another exercise activity he enjoys. 

He and his wife met with a dietitian once when he was first diagnosed, but he has not had any recent diabetes education. He states that his wife made some dietary changes at home after his diagnosis, but they still eat out for many meals and have slipped back into familiar eating patterns. 

Mr. Barton is concerned that he will need to start on insulin. Although he is not fearful of injections, he has read that insulin may lead to weight gain -- he does not want to gain more weight because he is afraid it may worsen his back pain and increase his CVD risk. 

A GLP-1 receptor agonist was added to his treatment to help this patient meet his goal of improving glycemic control without causing weight gain.

Based on Mr. Barton's initial presentation and laboratory values, what treatment options would you recommend to treat his hyperglycemia and minimize weight gain? (Please select the most appropriate response.)

A.    Discontinue glipizide ER, continue metformin 1000 mg twice daily, and add basal insulin once daily. 

B.    Continue metformin 1000 mg twice daily, decrease glipizide ER to 5 mg daily and add exenatide 5 g twice daily. 

C.    Continue metformin 1000 mg twice daily and glipizide ER 10 mg daily and add sitagliptin 100 mg daily.

D.    Either answer "B" or "C" would be appropriate.

For the correct answer, please click here.