Treatment Intensification in Type 2 Diabetes: 3 Cases
When intensifying T2DM therapy to reach glycemic goals, newer agents target common comorbidities. Which would you choose in these 3 scenarios?
Patient is 52-years-old with a 5-yr history of T2DM. She is taking metformin but A1c is creeping up. BMI is 30 and weight loss is difficult. Considering her background, which of the agents above would you select as an add-on to metformin?
Answer: C. Semaglutide. The ADA recommends adding either a GLP-1 receptor agonist or SGLT2 inhibitor to metformin in patients who will benefit from weight loss in addition to tighter A1c control.
Patient is a 65-year-old man with T2DM and stable CHF. He is taking metformin and has been on basal insulin for 2 years but A1c continues to trend upward. Which of the antihyperglycemics above would be the most appropriate add-on therapy for this patient?
Answer: E. Dapagliflozin. The ADA recommends a SGLT2 inhibitor in patients with a history of heart failure if A1c remains above goal.
The patient is a 48-year-old woman with T2DM of 7 years' duration. She has been on a stable dose of metformin since diagnosis but her A1c remains above goal. She is a candidate for additional therapy but is concerned about cost and about needles. Which of the above would you choose?
Answer: C. Glimepiride. Considering this patient's financial concerns and reluctance to use an injectable medication, the oral newer-generation sulfonylureas would be an appropriate choice after metformin.
____________________________________________________
Dr Sarkar is an assistant professor of medicine at Johns Hopkins University School of Medicine. You can follow her on Twitter at @SudiSarkar
Choice of antihyperglycemic agent after metformin can now be selected to also address comorbidites often seen in T2DM patients. Each of the 3 patients in this short case quiz presents a challenge as well as an opportonity to optimize diabetes care. Â
