Mrs.
S. returns for follow up 2 years after the initial visit and diagnosis of Type
2 diabetes and despite continued adherence to her diet and exercise plan she
has gained 25 lbs in weight and her HbA1c is 9. She has followed up with the
nutritionist who feels she is compliant with her diet. Six months ago you
started her on Glipizide and gradually increased the dosage, she is currently
taking the maximum dosage. She is reluctant to use insulin. Would you now?
1.
Have her see the nutritionist and diabetes educator for further lifestyle
intervention
2.
Switch to another oral agent such as metformin.
3.
Add another oral agent such as metformin.
4.
Consider adding long acting insulin before bedtime (BIDS therapy)
In
most patients with diabetes there is a general trend towards deterioration in
control with time. Most patients will require additional therapy and the
addition of another agent such as metformin is the most appropriate choice at
this time. This is a good choice especially for people who are overweight. As
metformin has gastrointestinal side effects, it should be started at a low
dose and titrated slowly. Adding a further hypoglycemic agent will produce an
additive effect on glucose lowering which will be greater than switching to a
different oral agent While Mrs. S may at some point require insulin this is
not necessary at this point.
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