Case 2: Type 2 Diabetes Uncontrolled on Oral Agent Therapy


Mr. W is a 53-year-old man who recently moved into town. He selected you as his primary care physician and has come in for follow-up of type 2 diabetes mellitus.

Mr. W was diagnosed with diabetes eight years ago, after his blood glucose was found to be elevated during routine lab work. He did not recall having symptoms of hyperglycemia at that time. He received instruction on nutrition and exercise. Two years later, his blood sugars were noted to be elevated, and he was treated with glyburide. Two or three years ago, metformin was added to his treatment regimen.

At the first visit, you performed a complete history and physical. His only complaint at the time was of occasional burning sensations in his feet at night, indicating probable diabetic neuropathy. He was not routinely monitoring his fingerstick glucoses.

Current Medications:

Physical Exam:

The rest of your exam was unremarkable. You requested his previous blood work, drew blood for a new chemistry panel, and referred him to an ophthalmology consultation. The subsequent ophthalmology consultation showed nonproliferative diabetic retinopathy with the recommendation of a follow-up exam in 6 months.

When the chemistry panel results are received, you note the following:

CBC Urine
Na+ 143 meq/L Microalbumin/creatinine ratio 45 µg/mg (normal is <30)
K+ 4.1 meq/L  
LDL 104 mg/dL  
HDL 27 mg/dL  
Fasting triglycerides 242 mg/dL  
FPG 199 mg/dL  
A1C 8.8%  

When Mr. W’s lab results are obtained from his previous physician, you note that his A1C was 6.9% 2 years ago, 7.5% 8 months ago. Results of his labs show an increase in Hg A1C to 8.8%. The current AACE recommendations are for A1C to be <6.5%; the ADA recommends <7%.1,2

Mr. W. should be reminded about the importance of lifestyle issues (eg, diet and exercise) as integral components of his ongoing treatment, as well as the necessity for him to monitor his BG levels and maintain a daily BG record. A referral to a diabetes educator should be provided.


Treatment Options

Participants are encouraged to read through all the treatment options for feedback on the potential benefits and limitations of each.

Treatment Option A: Addition of a Third Oral Antidiabetes Drug (eg, thiazolidinedione [TZD])

Treatment Option B: Initiate Insulin Glargine in Addition to 2 OADs; Follow Up

Treatment Option C: Initiate Multiple Daily Injections (MDI)

Treatment Option D: Initiating Treatment With Analog Mix Insulin



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