Mrs. O’Doole is a 34-year-old of Irish descent. She works as a florist and is married with three children. She arrives at your clinic for her annual wellness exam. Her blood pressure is 130/84 mmHg, pulse 65, BMI 24 kg/m2 and her physical exam is notable for acne and mild hirsutism. Her only current medication is oral birth control pills. She recalls starting OCP, 15 years prior, due to irregular menses.
Based upon her medical history and physical, you believe it would be prudent to screen Mrs. O’Doole for type 2 diabetes. You discuss your recommendations with her and she agrees be tested. The lab returns a fasting plasma glucose (FBG) of 112 mg/dL. You share these results with your patient and inform her that, while only mildly elevated, she has impaired fasting glucose. She was started on lifestyle modifications plus dietary modifications, and exercise for weight loss.
At a follow-up appointment 6 months later, Mrs. O’Doole tells you, despite good intentions, she has not been able to adhere to any meaningful lifestyle changes; in fact she has gained 5 pounds. At this time her repeat fasting plasma glucose shows FPG 138 mg/dL. After discussing management options with her, you decide the best management would be:
Answer: C. metformin + lifestyle modification
Mrs. O’Doole’s FPG (138 mg/dL) suggests she has progressed from prediabetes to diabetes (this should be confirmed on a repeat FPG). Highly motivated, newly diagnosed patients, with an A1C already near target, may be given the chance to try lifestyle modifications before the introduction of antihyperglycemic medications for glycemic control. However, this patient has not been able to implement these modifications to a clinically beneficial degree. At the time of diagnosis, unless there are contraindications, metformin is considered first-line therapy for type 2 diabetes. Incidentally, the addition of metformin may decrease her PCOS-associated hirsutism.
American Diabetes Association. Standards of medical care in Diabetes – 2013. Diabetes Care. January 2013; 36(Suppl. 1):S11-S66. Available at http://care.diabetesjournals.org/content/36/Supplement_1/S11.full. Accessed Jan. 11, 2013.
Goodarzi, M. Epocrates Online Diseases. Polycystic ovary syndrome. Updated June 18, 2012. Available at http://www.epocrates.com. Accessed Oct. 21, 2012.
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.