A 36-year-old woman who has had Type 2 diabetes for 2 years is evaluated because she has just discovered that she is 5 weeks' pregnant. She currently takes glyburide and rosiglitazone. Her most recent hemoglobin A1c value was 8.2%. She says she is not checking her blood sugar level frequently but tells you her fasting glucose concentrations have been in the 140 to 160 mg/dL (7.77 to 8.88 mmol/L) range. She has no known microvascular or macrovascular complications of diabetes.

Her body mass index is 39; blood pressure is 120/80 mm Hg. Physical examination shows the presence of acanthosis nigricans. Renal and liver functions are normal.

QUESTION:

Which of the following is the most appropriate treatment for this patient?

A. Add premixed 70/30 insulin before breakfast and dinner.

B. Continue glyburide and rosiglitazone, refer to a nutritionist for meal plan revision, and prescribe an exercise regimen. 

C. Continue rosiglitazone, stop glyburide, and start intensive insulin therapy with preprandial insulin lispro and neutral protamine Hagedorn (NPH) at bedtime. 

D. Stop glyburide and rosiglitazone and start intensive insulin therapy with preprandial insulin lispro and NPH at bedtime.