A woman, 72 years of age, type 2 diabetes, obesity, taking metformin, GLP1, ARB, and antidepressant (SSRI). Lost 20% total body weight in the past year. Recently complaining of dizziness and weakness. Glucose levels in the 60’s at home, at which time had symptoms of hypoglycemia. Glucose-lowering medications (metformin and GLP-1) were stopped. Continued to complain of dizziness and weakness especially in the morning.

Man, 52 years of age, type 2 diabetes, obesity class II on Victoza. He was very pleased with treatment response, lowering glucose levels, feeling full and more satisfied, but having a skin reaction.

Recently I had a patient who was referred to me due to increased glucose levels, which happens all the time. However, this patient was referred because of the recent changes in fasting glucose levels. After attending a group diabetes class, the patient seemed to be improving self care and average fasting glucoses had dropped from around 165 mg/dl to 130 mg/dl. The readings held like this for two months and then started to rise again....

I asked a patient with erratic glucose levels where he usually gave his insulin injections to which he responded, "In my arms." I asked, "Could you show me where?" The patient promptly rolled up his sleeves and pointed to the vein in his antecubital space.

A woman in her 60s, extremely insulin-sensitive with type 1 diabetes, came for a review of carb counting and blood sugar logs.  Pt had been running blood sugars above the target range. When asking pt why she thought her blood sugars were running high, she stated she was fearful of having low blood sugars....

Recently a patient presented to our outpatient diabetes education center. His A1C had historically been elevated, despite the initiation of insulin therapy and increasing doses. The patient reported that he had taken all insulin doses as ordered, but was frustrated with his lack of progress....

I am a primary care provider in a small private office. A long-term patient of mine, 32 years of age, was recently diagnosed with type 1 diabetes. His insurance is now one I do not participate in. Until his recent diagnosis, he visited annually and paid out of pocket. He wanted to stay with me for his care....

In the last four issues, we discussed a new software that can go through over 6 million possible treatments using anywhere from 1 to 5 drugs for an effective treatment for type 2 diabetes. Along with determining the best treatment for the patient, it includes the ability to put in what the patient can afford in their budget. Dr. John Interlandi, one of our readers, has submitted a counterpoint to using this software to decide the best treatment options. Dr. Interlandi shares his concerns about the use of AI in medical decision making.  

Part 4: Using Computers to Determine Type 2 Treatment: The first three articles in this series focused on what makes treating type 2 diabetes so difficult: the overwhelming number of medicines and combinations; finding effective treatments that work with our patients' insurance coverage and household budgets; and incorporating factors beyond glucose control, such as body weight, adherence, and side effects, into our decisions. In this installment, we discuss how those problems can be represented in ways that computers can understand.

Part 3: Trade Offs — Clinical Decision Making for Patients with Type 2 Diabetes: In the previous series of articles, we discussed the complexity of clinical decision making and the role the cost plays into that decision. Cost is only one dimension of the complex process of deciding the appropriate next steps in the treatment of type 2 diabetes. In this article, we will discuss the other aspects of clinical decision making, and how clinicians can think about the trade-offs involved in making medication choices.