Type 2 Diabetes, on Insulin, Not at Goal: 2 Case Studies
Meet 2 type 2 diabetes patients on multiple antihyperglycemics but still not meeting the ADA recommended A1c goal of 7%. What are the next best steps?
The 2 patients with type 2 diabetes in these short cases will be familiar to many primary care physicians - they are both on multiple antihyperglycemic medications and appear to be adherent to their regimens and yet are still above the American Diabetes Association recommended A1c goal of 7%.
Consider the options for next steps with the short history provided by Dr Sudipa Sarkar in mind. What's the next best step?
Case #1. A 39-year-old man with T2D diabetes presents to clinic for routine follow-up. Despite treatment with multiple agents, his point of care A1c is above goal, at 7.9%
Case#1. A 39-year-old man with T2D, A1c not at goal. He does not want to initate prandial insulin. Which of the options above would be the optimal next choice for medications?
Answer: A. Divide insulin glargine into 2 divided doses of 40 units 2x/d. If concentrated insulin is not an option, it might be best to divide the patient’s relatively large single dose of insulin glargine into 2 divided doses so that the dose is better absorbed.
Case #2. A 49-year-old woman with a 15-yr history of T2D presents to clinic for routine follow up. She is on several agents to lower her hyperglycemia, including insulin at night, but her point of care A1c today is 8.5%
Case #2. A 49-year-old woman with a 15-yr history of T2D. Her highest glucose reading is before dinner; lunch is her largest meal. What would be the next reasonable step in her treatment?
Answer: A. Add rapid-acting insulin before lunch, stop glimepiride. If a patient is already on basal insulin that has been titrated to goal and A1c is not optimal, then prandial insulin can be considered. This step is recommended by the American Diabetes Association in the 2019 Standards of Medical Care in Diabetes.
