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Question #824

Mrs. Hunter is a 36-year-old African-American who comes to your office for her annual wellness exam. She is overweight (BMI 27 kg/m2), but is otherwise healthy. She jokes that she “just can’t seem to lose that extra baby weight” after giving birth 3 years ago. However, her daughter recently started preschool, so she has been able to go to her new gym several times per week. In fact, one of the added bonuses of her membership is the free, weekly nutrition and exercise support groups. In addition to her routine labs, you order an A1C, which comes back elevated at 7.1%. This measurement is confirmed several days later. Based on Mrs. Hunter’s profile, you encourage lifestyle modifications and start metformin with an A1c target of <7%.

You and Mrs. Hunter set a goal for A1C <6.5%. She returns 3 months later for a follow-up visit and her office labs show an A1C 6.8%. You congratulate her on her progress and ask her to return in another 3- 4 months. When she does, she is above her goal with an A1C 8.1%. She explains that she has gone back to full-time work and just doesn’t have the time to get to the gym anymore. At this time, what would your next step be and what would her individualized glycemic targets be?

Correct

Answer:  D. Encourage lifestyle modifications and and continue with metformin

After allowing a 3-6 month trial period of lifestyle modifications, if on a repeat visit the A1C indicates the attempt has been unsuccessful, pharmacotherapy should be initiated. With her current A1C at 8.1%, monotherapy, typically with metformin unless there are contraindications, would be started. The glucose-lowering effect of metformin is considered to be high and would be expected to lead to an A1C reduction of 1-1.5%. While she has had difficulty maintaining lifestyle modifications, the more stringent A1C goal, as long as it is well tolerated (no significant hypoglycemia, treatment side effects) would still be appropriate given her age, health status and disease duration. A1C goals should be individualized and modified as necessary. She should be encouraged to continue with lifestyle modifications as well as metformin. And provide her alternatives for physical activity rather than going to the gym.

Reference(s):

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.

Incorrect