Case Studies

Two Orals Fail in T2DM Patient


Case vignette

A 63-year-old Hispanic woman with type 2 diabetes (T2DM) has been under your care for ten years and she was diagnosed with T2DM six years ago. In addition to long-standing hypertension and hypercholesteremia, she has a BMI (body-mass index) of 31 kg/mas well as a family history of cardiovascular disease.

However, she has never had a cardiovascular event and does not report any cardiac symptoms.   

She monitors her fasting glucose level twice a week and her morning fasting glucose levels have ranged between 140 and 160 mg/dl. She is taking metformin (1,000 mg b.i.d.) and extended-release glipizide (10 mg b.i.d.). You have been seeing her every six months since her diagnosis of T2DM six years ago. Her hypertension has been successfully controlled with hydrochlorothiazide (25 mg daily) and lisinopril (20 mg daily) and her hypercholesteremia with simvastatin (20 mg daily). Additionally, she takes aspirin (81 mg daily). 
The patient has struggled to manage her weight and has been counseled about lifestyle changes. She has lost weight on various diets (~ 10-15 pounds), however each time she regains all of the weight lost. She tries to walk 30 minutes three times a week. Her BMI has fluctuated between 30 and 32 kg/m2 for the past decade.
A recent blood test showed her HbA1c level to be 8.0%. Her other laboratory tests have consistently shown normal results for liver, renal, and thyroid function. Physical examination shows normal blood pressure (118/78 mmHg) as well as normal cardiorespiratory, abdominal, and neurologic findings.  
The patient has health insurance through her employer, which includes prescription drug coverage. Concerned about her inability to reach her glycemic goal (HbA1c of 7.0%), she seeks advice about whether a change in medications might help her manage her T2DM more effectively.
Treatment Options
Which one of the following treatment options do you think would be most appropriate for this patient?
1.     Add a thiazolidinedione (TZD)
2.     Add a glucagon-like peptide-1 (GLP-1) agonist
3.     Add insulin

Management options

1. Thiazolidinedione (TZD)

Zachary T. Bloomgarden, MD, FACE

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

Carol Wysham, MD

3. Insulin Therapy

Charles F. Shaefer, Jr., MD, FACP, FCCP
General Internist