A 45-year-old African American man with a history of obesity and hypercholesteremia has been under your care for the past three years. He has a family history of both T2DM (type 2 diabetes mellitus) and cardiovascular disease but no history of cardiovascular events.A 45-year-old African American man with a history of obesity and hypercholesteremia has been under your care for the past three years. He has a family history of both T2DM (type 2 diabetes mellitus) and cardiovascular disease but no history of cardiovascular events.
He reports no cardiac symptoms and no polyuria, polydypsia, or fatigue.
About a year ago, the patient requested blood glucose screening because his brother had just been diagnosed with T2DM. At that time, his HbA1c (glycated hemoglobin) level was 5.8%. You recommended weight loss and exercise of 30 minutes daily. The patient reports intermittent success with weight loss, but has been unable to sustain it. He reports attempting to walk most days, but notes that work and family obligations as well as inclement weather often make this impossible.
The patient’s HbA1c has risen to 6.3% since you last examined him, an increase of 0.5%, and a recent blood glucose test showed an FPG (fasting plasma glucose) of 115 mg/dL. He has also gained 4 pounds, resulting in an increase in BMI (body-mass index) from 31 to 32 kg/m2 over the past year.
His hypercholesteremia is treated with simvastatin (20 mg daily). He also takes aspirin (81 mg daily). He reports taking these medications consistently. With medication, his LDL (low-density lipoprotein) is at goal; whereas his HDL (high-density lipoprotein) and triglycerides are 35 mg/dL and197 mg/dL respectively. Additional lab tests show normal renal and liver function, including a serum creatinine of 0.9 mg/dL, a SGOT (serum glutamic oxaloacetic transaminase) of 36 mg/dL, and a SGPT (serum glutamic pyruvic transaminase) of 42 md/dL. His thyroid function tests are also normal.
Physical examination shows normal cardiorespiratory, abdominal, and neurologic findings. His blood pressure is normal (128/78 mmHg). The patient has acanthosis nigricans behind his neck.
The patient seeks advice on how to manage his situation to prevent T2DM.
Which one of the following treatment options, any one of which could be considered correct, do you think would be most appropriate for this patient?
1. Reinforce lifestyle changes
2. Reinforce lifestyle changes plus initiate metformin
3. Reinforce lifestyle changes plus initiate TZDs