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Treatment Changes

Sep 16, 2017

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?


Answer is C. Add a pre-meal rapid-acting insulin

Educational Critique: 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 no 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 glucose<150-160, A1C=7%. When fasting glucose is at target, but postprandial glucose levels (PPG>180 mg/dL) and A1C remain above target, the addition of prandial insulin should be considered.

Reference: American Diabetes Association