Case Studies

Basal Insulin Fails in T2DM Patient


Case vignette

A 52-year-old Caucasian man was diagnosed with type 2 diabetes (T2DM) eight years ago and has been under your care for the past three years. His current treatment regimen includes glargine (50 units daily), metformin (1,000 mg b.i.d.), and glimepiride (2 mg daily), as well as lisinoprol (20 mg daily), and atorvastatin (20 mg daily).

Recent blood tests came back normal for lipid levels as well as renal and liver function, but showed an HbA1c level of 8.0%.

In his most recent physical, you found this patient to have mild retinopathy but normal blood pressure (110/80 mmHg) and no symptoms of gastroparesis. You found no signs of cardiovascular disease despite a family history of both athlerosclerosis and myocardial infarction. You also noted that the patient has gained an average of two pounds a year since he first came to your office, and currently weighs 210 pounds (giving him a BMI of 32 kg/m2). The patient reports making efforts to exercise by jogging about four times a week but finds it difficult to control food intake. He says he understands that weight loss might help control his blood sugar but finds himself uncontrollably hungry, particularly at night, and is unable to resist the high-calorie foods brought into the house by his teenage children.

Although self-employed, this patient currently has health insurance that includes prescription drug coverage. He seeks advice about whether a change in medications might help him reach his glycemic goal (HbA1c of 7.0%) and prevent potential neurologic and cardiovascular complications.

Treatment Options

Which one of the following treatment options do you think would be most appropriate for this patient?

  1. Add mealtime insulin
  2. Add pre-mixed insulin twice a day
  3. Add a GLP-1

Management options

1. Mealtime insulin

Kevin A. Peterson, MD, MPH
Family Medicine

2. Pre-mixed insulin

Doron Schneider, MD, FACP
General Internist

3. Glucagon-like peptide-1 (GLP-1)

Irl B. Hirsch, MD