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Once a Pump, Always a Pump? Wrong!

A man, lean and muscular, with type 1 for over 25 years, has been pumping for 15 years and wearing a sensor for the past five years. Glucose levels have been very erratic. We checked his sites and were concerned that the erratic glucose levels were mostly related to lack of subcutaneous fat and scar tissue, so he was actually getting insulin into his muscle, scar tissue, or subcutaneous tissue at various times. Also, the patient wears an OmniPod and thought it could only be in one particular direction.

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International Textbook of Diabetes Mellitus, 4th Ed., Excerpt #126: Beta-Cell Mass and Function in Human Type 2 Diabetes Part 2

The role of beta-cell death and regeneration: The loss of beta-cells in T2DM has been mainly attributed to increased beta-cell death due to apoptosis and other forms of cell death, possibly driven by adverse environmental conditions and probably mediated by several intracellular mechanisms. Apoptosis is a type of programmed cell death morphologically characterized by cell rounding up, bleb formation and chromatin condensation. As a matter of fact, in autoptic pancreatic samples apoptosis has been shown to be significantly increased in both obese and lean type 2 diabetic cases as compared to BMI-matched, nondiabetic controls.

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Clinical Case Vignette: Treatment Next Steps

Mrs. Hunter is a 36-year-old African-American who comes to your office for her annual wellness exam. She has excess weight (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 that she has been participating in their 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, what would a reasonable next step be? A. Encourage lifestyle modifications and start metformin with an A1C target of < 7.0%.
B. Encourage lifestyle modifications and start metformin with an A1C target of < 6.0%.
C. Encourage lifestyle modifications and do not initiate drug therapy at this time.
D. Encourage lifestyle modifications and start metformin and a sulfonylurea.
Follow the link for the answer.

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