A 42-year-old patient was diagnosed with type 2 diabetes approximately one year ago and is currently taking metformin, a DPP-4 inhibitor, and a basal insulin dose (current daily dose .9 U/kg/day). Despite good compliance with her diet, exercise and medication regimen, she reports postprandial glucose measurements of usually about 190 mg/dL. Her current A1C is 7.6%. Which of the following changes in her management do you consider most important?
Select one answer:
Answer: C. Add a pre-meal rapid-acting insulin
While the ADA/EASD’s implementation strategies to pharmacologically achieve glycemic targets while minimizing side-effects need to be individualized for each patient, a general progression exists. Assuming there are not any contraindications, metformin is the optimal first-line medication. Individualized A1c goals are assessed approximately every 3-6 months with additional drugs being added/adjusted as needed to achieve the A1C goal (1-drug monotherapy, 2-drug combo therapy, 3-drug combo therapy, complex insulin strategies). After a patient starts a basal insulin regimen they can self-titrate their insulin dosing to their pre-agreed fasting glucose goals. The American Diabetes Association recommends the following glycemic recommendations for most adult, nonpregnant individuals with type 2 diabetes. Fasting glucose <130, postprandial glucose<180, mean plasma glucose180 mg/dL) and A1C remain above target, the addition of prandial insulin should be considered. 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. 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.