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Question #833

Mrs. Wilson is an overweight 71-year-old African-American patient who has come to your clinic today for a new patient visit. She recently moved to the area to live with her daughter and is concerned about her diabetes care plan. She was diagnosed with type 2 diabetes 12 years ago at a wellness check through routine screening. In hindsight, she wonders if maybe she “went undiagnosed for a while” because she “didn’t get to the clinic very often and was having some problems with frequent urination at night” before she was screened. She currently takes metformin, glyburide, captopril, pravastatin, aspirin and has recently titrated to .6 U/kg/day insulin NPH as a nightly basal dose. Her current A1C goal is <7.5% and she has been working hard to get to that level. However, for the first time in her life, she is finding herself to be nauseated and irritable in the morning, but always feels better after a little breakfast. She states she feels “pretty good for her age” although she occasionally has “a little chest tightness when walking more than 4 or 5 blocks.” Last time she remembered to check it a few days ago, her postprandial glucose was a little high at 214 mg/dL. Her office A1C is 8.6%.

Based on her history, what would be an acceptable individualized A1C goal for this patient?

Correct

Answer:  C. A1C<8.0%

Less-stringent A1C targets are acceptable in certain individuals, such as those with a history of hypoglycemia, presence of important comorbidities/complications, limited life expectancy, long-standing disease duration, risks associated with hypoglycemia, established vascular complications and difficulty achieving target A1c despite education, support and polypharmacy. This patient has several factors that would support a less-stringent A1C: advanced age, polypharmacy, lack of an established support network, and a history of hypoglycemia putting her at increased risk for falls, arrhythmias, confusion, symptoms of cardiovascular disease and comorbidities.

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. 2015; 35(6):1364-1379.

Incorrect