Case 2: Treatment Options

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

There are few long-term advantages to adding a third oral antidiabetes drug (OAD). Although A1C may improve over the short term, physicians should remember that diabetes is progressive; at some point, it will likely be necessary to initiate some form of insulin therapy.³

In a study by Yale and colleagues, patients who were on metformin and sulfonylurea and had inadequate glycemic control were randomized to a TZD vs placebo. The mean A1C lowering in the TZD group was 1.4%; mean reduction in FPG was 50 mg/dL.⁴

Athough a 1.4% decrease in A1C is clearly beneficial, this would be inadequate in our patient, whose A1C at presentation is 8.8%. Prescribing a TZD in this case may decrease his A1C to 7.4%, but studies show that this may not take effect for up to 26 weeks.⁵ Since Mr. W. already has early neuropathy, retinopathy, and an FPG of 199 mg/dL, it is important to decrease his FPG more quickly. This option, therefore, would be suboptimal therapy, and optimal glucose control would not be attained. Please select another treatment option.

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