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Initiating Therapy

Dec 16, 2017

One of your patients has referred her 21-year-old stepson for a new patient exam. He has recently arrived home from college for the summer and she is concerned because he always seems to be thirsty. When prompted, she recalls her husband saying his ex-wife struggled with her weight and took “pills for her blood sugar.” Physical examination is notable for mildly elevated BP (137/84) and BMI 26 kg/m2. He denies any cigarette or alcohol use, states his favorite activities revolve around video games, and that he doesn’t really enjoy any physical activities. Labs are notable for random plasma glucose 312 mg/dl, UA positive for glucose. What would your initial drug therapy strategy be?


Answer: D. Initiate insulin therapy

Educational Critique: According to the ADA/EASD recommendations, insulin therapy should be strongly considered from the onset for patients who present with severe hyperglycemia (?300-350mg/dL; A1C?10-12%) with or without catabolic features. Insulin therapy is mandatory if patients exhibit catabolic features or if ketonuria is present. Once patients’ symptoms/glucotoxicity/metabolic state have been resolved and stabilized, unless there is evidence of type 1 diabetes, it may be possible to modify the treatment strategy to reflect partial or complete tapering of the insulin, switching to noninsulin hyperglycemic agents or combination therapy. Environmental factors and genetics strongly influence the development of type 2 diabetes. In general, if one parent was diagnosed with type 2 diabetes before age 50, the child has a 1 in 7 risk of developing type 2 diabetes; if the parent was diagnosed after age 50, the child’s risk is 1 in 13; if both parents were diagnosed with type 2 diabetes, the child’s risk jumps to 1 in 2.  -- American Diabetes Association; Diabetes Care 2015 Jan; 38(Supplement 1): S41-S48. https://doi.org/10.2337/dc15-S010