A 53-year-old African-American man with a history of type 2 diabetes mellitus (T2DM), hypertension, and osteoarthritis is in clinic for follow-up of T2DM. His only complaint at this time is polyuria. Current medications include metformin, 1000 mg twice daily; lisinopril, 20 mg/d; amlodipine 10mg/d; aspirin, 81 mg/d; simvastatin, 20 mg/d; and acetaminophen 1000 mg TID. He is “mostly” adherent to the regimen but says it is still difficult for him to take multiple medications multiple times a day.
Results of his physical examination today and recent laboratory findings are WNL, with the exception of an A1C of 9.2%, up from 8.1% measured 3 months ago. Vitals are: weight, 82 kg (previously 85 kg); blood pressure, 138/88 mm Hg (previously 141/86 mm Hg); and heart rate, 74 beats/min. He does not bring a home blood glucose log to clinic. He is a manager at a retail store, works an erratic daytime schedule, and often skips breakfast or lunch. He also has a hard time following his diabetic diet. He states that he is often very thirsty, but is proud that he has stopped drinking sodas and is drinking lots of water. He also tells you that he is grateful that while his insurance provider was recently changed, you are still in his network.
Answer: B. Initiate insulin therapy
Insulin therapy should be considered as an option in all patients requiring dual therapy. Insulin becomes the most appropriate choice (in addition to metformin) when the patient is unlikely to reach target A1C on oral agents and/or the patient has significant hyperglycemia (>300mg/dL or symptoms of hyperglycemia).1 While no home blood glucose readings are available, the patient is reporting symptoms of hyperglycemia (ie, polydipsia, polyuria) and guidelines support starting insulin therapy sooner rather than later in this patient.1
While a sulfonylurea (option A) is an appropriate second-line option, it is not the best option for this patient at this stage of the disease as the drug is not sufficiently potent to lower his A1c to the target goal of <7% and treat the symptoms of hyperglycemia. This also holds true for initiating liraglutide (option C), even at the maximum dose of 1.8 mg daily.
The patient is already taking the optimal daily dose of metformin (2000 mg/day) and therefore increasing the dose (option D) would not be expected to provide any further significant decrease in A1C. Saxagliptin (also option D) is associated with only a modest decrease in A1C and so adding the drug at this time is unlikely to help the patient achieve his glycemic goals.