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Clinical Case Vignette Follow-up: Two Steps Back

May 26, 2018

Mrs. Hunter is 36-year-old woman who is African-American. She comes to your office for her annual wellness exam. She has excessive weight (BMI 27 kg/m2), but is otherwise healthy. She jokes that she, “just can’t seem to lose that extra baby weight” after giving birth 3 years ago. However, her daughter recently started preschool so she has been able to go to her new gym several times per week. In fact, one of the added bonuses of her membership is that she has been participating in their free, weekly nutrition and exercise support groups. In addition to her routine labs, you order an A1C, which comes back elevated at 7.1%. You and Mrs. Hunter set a goal for A1C<6.5%. She returns 3 months later for a follow-up visit and her office labs show an A1C 6.8%. You congratulate her on her progress and ask her to return in another 3–4 months. When she does, she is above her goal with an A1C 8.1%. She explains that she has gone back to full-time work and just doesn’t have the time to get to the gym anymore. At this time, what would your next step be and what would her individualized glycemic targets be?


Answer: A. Encourage lifestyle modifications and start metformin with a target A1C< 6.5%

Educational Critique: After allowing a 3–6-month trial period of lifestyle modifications, if on a repeat visit the A1C indicates the attempt has been unsuccessful, pharmacotherapy should be initiated. With her current A1C at 8.1%, monotherapy— typically with metformin unless there are contraindications—would be started. The glucose-lowering effect of metformin is considered to be high and would be expected to lead to an A1C reduction of 1–1.5%. While she has had difficulty maintaining lifestyle modifications, the more stringent A1C goal, as long as it is well-tolerated (no significant hypoglycemia, treatment side effects) would still be appropriate given her age, health status, and disease duration. A1C goals should be individualized and modified as necessary. She should be encouraged to continue with lifestyle modifications as well.