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CLINICAL CASE VIGNETTES: Diabetes Management Steps

Jun 30, 2018

Mr. Huang manages his diabetes with his lifestyle modifications, metformin, and linagliptin, and returns every 6 months for follow-up visits. Three years after initiating this treatment plan, he returns to your clinic for his 6-month check-up. When asked how his diabetes management is going at home, he shares that recently he has been “unable to really get out and get as much exercise as he knows he should due to his creaky, old knees acting up.” His current office A1C is 8.8%. You discuss with him what the next management steps may be to achieve his individualized glycemic goal. What would your next medical management step be?


Answer: B. Add a long-acting insulin analogue

Educational Critique: Moving to a 3-drug combination would be appropriate in this individual. The addition of a basal dose of a long-acting insulin analogue would be the most appropriate choice for this individual. Rapid-acting insulin analogues are used for daytime bolus dosing. Both the DPP-4 inhibitors and the GLP-1 agonists are based on the incretin system. When new agents are added, they should have complementary mechanisms of action. In some cases, when adding a third agent, a sulfonylurea could be an appropriate choice. However, once A1C?8.5%, it is unlikely that a noninsulin agent will be adequately effective at lowering glucose levels.