Mrs. F. is a 60 year old
woman with a 10 year history of type 2 diabetes, she has documented
nephropathy with a creatinine of 1.3 mg/dl. Her glycemic control has however
deteriorated over the 6-12 months despite maximal dosage of an glucosidase
inhibitor such as acarbose and sulfonylurea.
Her HbA1c has risen from 8.5%
to 9.6% in the last six months. You elect to discontinue the acabose /
sulphonylurea combination, your next intervention would be:
Refer
her to an endocrinologist for consideration of an insulin pump.
Add
metformin to her regimen.
Institute
treatment with bedtime insulin and a sulfonylurea.
Institute
treatment with intensive insulin therapy.
Insulin
pump therapy is most appropriate for individuals with type 1 diabetes. While
multiple daily insulin injections may one day be necessary a more simple
regimen is easier for the patient. Metformin should not be used in people with
any significant impairment in renal function. Also care should be taken with
sulfonylureas in this group of patients. The most appropriate intervention in
this example is the institution of bedtime insulin after appropriate
education.
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