Your 42-year-old, overweight patient was diagnosed with type 2 diabetes (A1C 7.7%) five months ago. You discussed the diagnosis with him, prescribed metformin and provided lifestyle modification education resources. He missed his follow-up appointment, so you called him to schedule a return visit. At this appointment, he shares some of the positive lifestyle modifications he has made and that he has been taking his metformin consistently. He currently takes 2000 mg metformin per day. At this visit, his A1C is 9.4%. All of the following are reasonable treatment options EXCEPT:
Select one answer:
Answer: A. Metformin+ lifestyle modifications
According to ADA/EASD guidelines, once A1C=9%, glycemic targets are hard to achieve with monotherapy. If, after approximately a 3-month treatment period, monotherapy does not achieve or maintain target A1C, a second oral agent, a GLP-1 receptor agonist or a basal insulin should be added. Adding a second agent is associated with an additional A1C reduction of 1%. A, B, and C are all acceptable 2-drug combinations. Additional education, support and more frequent follow-up would be warranted.
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.