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Test Your Knowledge Question #796

A 41-year old patient with a BMI of 39 kg/m2 returns for a follow-up visit 3 months after initiating metformin. She is highly sensitive to her weight and has tried to implement lifestyle modifications, but is finding it difficult to make any meaningful changes in her diet or exercise routines. Her current A1C is 7.7%, with a target goal A1C<7%. In addition to discussing consideration of bariatric surgery, which drug class might you add?

Select one answer:

Correct

 

Answer: D. GLP-1 receptor agonist
Thiazolidinediones have been shown to be effective at improving insulin sensitivity, however their use can lead to an overall increase in body weight due to an increase in lower body fat secondary to adipocyte proliferation. Sulfonylureas are associated with weight gain as well. The use of metformin has been associated weight reduction/maintenance in heavier patients, DDP-4 inhibitors are considered weight neutral and GLP-1 receptor agonists are associated with weight loss, which can be significant in some patients. Bariatric surgery has been associated with a rapid and significant resolution of type 2 diabetes in severely obese individuals, with some individuals able to decrease or even discontinue their antihyperglycemic medications and may be considered in adults with type 2 diabetes and BMI>35 kg/m2 with type 2 diabetes associated comorbidities or type 2 diabetes that is difficult to control with medications or lifestyle modifications. There is currently insufficient evidence to recommend bariatric surgery for those with a BMI of 30-35 kg/m2, although small trials have demonstrated a benefit. Dietary modifications and increased physical activity are known to improve glycemic control, aid in weight loss and improve other cardiovascular risk factors.

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.

Shadid S, Jensen M. Effects of pioglitazone versus diet and exercise on metabolic health and fat distribution in upper body obesity. Diabetes Care. Nov.2003; 26(11):3148-3152. Available at http://care.diabetesjournals.org/content/26/11/3148.long. Accessed Oct. 17, 2012.

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.

Incorrect