Interactive diabetes case 2: Switching from oral agents to insulin in type 2 diabetes
- Lloyd Axelrod, MD
Lloyd Axelrod, MD
- Associate Professor of Medicine
- Harvard Medical School
A 56-year-old woman is referred to you for management of type 2 diabetes.
Nine years ago the patient experienced three to four months of polyuria, polydipsia, nocturia, dry mouth, and blurred vision. She had habitually consumed large quantities of orange juice and ginger ale, and had increased consumption several fold when polydipsia appeared. She weighed 188 pounds, was 5' 5" tall and had a body mass index (BMI) of 31.3 kg/m2. A random glucose level was 237 mg/dL (13.2 mmol/L) and the glycated hemoglobin (A1C) was 10.7 percent. The patient was treated for diabetes with a no-concentrated sweets, low fat diet, including substitution of diet beverages and water for juices and sodas, and with glyburide 5 mg by mouth once daily. Over the next six months, the A1C fell to 7.9 percent and the patient's symptoms resolved.
Over the ensuing years, the patient's weight increased to 199 pounds, the BMI increased to 33.1 kg/m2, the A1C level rose, and the use of oral agents increased. At the present time she takes glyburide 10 mg by mouth twice daily and metformin 1000 mg by mouth twice daily. The fasting glucose level is consistently 150 to 160 mg/dL (8.3 to 8.9 mmol/L) and the premeal values are in the 200 to 230 mg/dL (11.1 to 12.8 mmol/L) range. The A1C is now 9.7 percent. She eats three meals daily, follows her diet and counts carbohydrates. The nutritionist advises you that the patient is doing all of this reasonably well. You conclude that the patient is a secondary failure on oral agents. How would you manage the patient at this time?
●Add NPH insulin 20 units subcutaneously (SQ) daily at bedtime. (See "Interactive diabetes case 2: Switching from oral agents to insulin in type 2 diabetes - A1".)
●Add glargine insulin 20 units SQ daily at bedtime. (See "Interactive diabetes case 2: Switching from oral agents to insulin in type 2 diabetes - A2".)