Test Your Knowledge #528: An African-American Man with Type 2 Diabetes and Obesity, Part Three 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.

Mr. Barton’s lipid levels are well-controlled on his current dose of simvastatin. 

His blood pressure (135/82 mmHg), however, is above ADA and AHA guidelines (systolic blood pressure <130 mmHg and diastolic blood pressure <80 mmHg). Mr. Barton reported that his blood pressure is usually well controlled on his current medication regimen.

The physician made the following treatment changes and recommendations:

• Mr. Barton was instructed on giving himself an injection using the exenatide pen device, and provided with a prescription for exenatide 5 µg twice daily.
• His glipizide ER dose was reduced to 5 mg daily.
• He was continued on his current metformin dose, as well as his current lipid and hypertension medications.
• He was asked to stop by the office in 1 week to have his blood pressure rechecked.
• An appointment was made for a 3-month follow-up visit at the clinic.

Mr. Barton returned to the clinic for a repeat blood pressure check 1 week after his initial visit. His reading that day of 126/76 mmHg indicated that his current hypertension medication was satisfactory. 

Mr. Barton called in to the clinic 4 weeks after starting exenatide and reported that the mild nausea he experienced initially had resolved quickly and he was ready to advance his dose to 10 µg twice daily.

Mr. Barton and his wife returned for a follow-up visit with the physician 3 months after his initial visit. 

Mr. Barton attributed the weight reduction of 18 pounds to a decreased appetite and a new diet regimen given to him by the dietitian -- he and his wife found the diabetes education helpful and they returned for 2 follow-up visits with the dietitian. He also credited increased exercise for his weight loss, stating that he had purchased a treadmill 2 months earlier and was using it most weekday afternoons after work. 

Mr. Barton reported feeling a bit shaky after exercise and before dinner, but he usually felt better after eating. He also reported that nausea had reoccurred after starting exenatide at the higher 10 µg dose, but it had improved after about 2 weeks and now was only occasional. He did not describe any other GI side effects. 

Based on Mr. Barton’s presentation and laboratory values at the 3-month follow-up visit, what changes, if any, would you recommend? (Please select the most appropriate response.)

A.     Add a medication to improve his hypertension.

B.     Discontinue glipizide ER 5 mg daily.

C.    Continue the current medication regimen.

For the correct answer, please click here.