You talk to Elena about finding a way to add aerobic and weight-bearing exercise into her routine, and prescribe daily atorvastatin at 20 mg to treat her dyslipidemia. You then have her schedule a DXA assessment, which she does after returning from a planned vacation. You see her at a follow-up visit three months later and discuss results, which, with a femoral neck BMD T-score of -1.5, indicate low bone mass, but not osteoporosis.

BMD T-scores tend to underestimate fracture risk in patients with T2DM so you adjust this score by subtracting 0.5. You explain to Elena that BMD T-score tends to underestimate fracture risk in patients with type 2 diabetes so that her fracture risk is similar to a non-diabetic woman of a similar age with a T-score of -2.0. You also explain that this score indicates low bone density (or osteopenia) (BMD T-score<-1.0) but is still higher than the threshold (-2.5) for osteoporosis. Using an online calculator (e.g., https://www.shef.ac.uk/FRAX/tool.jsp), you calculate Elena's FRAX score and determine that she has a 15% risk of major osteoporotic fracture and an 0.8% risk of hip fracture in the next 10 years. You explain to Elena that, as with the BMD T-score, FRAX tends to underestimate fracture risk in patients with diabetes. Even so, these risk estimates are both well below the threshold for considering pharmacological therapy for osteoporosis in the National Osteoporosis Foundation (NOF) guidelines (3% for hip fracture and 20% for major osteoporotic fractures (MOF).

Elena has gained a pound since you last saw her, and her most recent laboratory tests show her A1C has climbed to 7.7%. You advise her to continue taking a daily supplement that includes 1,000 mg of elemental calcium and 800 IU of vitamin D. You also talk to her about the advisability of adding a second-line diabetes medication to control her blood glucose level. She pushes back at the idea of moving to insulin or adding any injectable agent.

What strategy for glycemic control would you choose for Elena?