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Which of the following is the best A. Add exenatide next step in therapy? B. Add insulin glargine C. Add pioglitazone D. Add sitagliptin E. Double his dosage of glipizide 20% 20% 20% 20% 20% A. B. C. D. E.
• This patient has poor glycemic control, despite combination therapy with metformin and extended-release glipizide (a sulfonylurea), and thus requires insulin. The standard method of initiating insulin therapy is to begin with a single daily injection of a basal insulin, such as insulin glargine, insulin detemir, or neutral protamine Hagedorn (NPH) insulin; this approach minimizes the risk of hypoglycemia. Starting doses in the 0.2 to 0.3 U/kg range will be well tolerated in most patients, with future titration based on the results of home glucose monitoring. • Dose changes are typically made in increments of 2 to 4 units every few days or weekly until the fasting glucose level is consistently in the range of 70 to 130 mg/dL (3.9 to 7.2 mmol/L). The addition of insulin glargine or insulin detemir to this patient’s regimen should result in a substantial reduction in his hemoglobin A1c value. • Randomized studies of stepped therapy in type 2 diabetes showed that most patients were able to achieve target hemoglobin A1c goals of 7% using a combination of oral antihyperglycemic agents and basal insulin therapy. If such a reduction is not achieved and postprandial hyperglycemia occurs, the addition of a mealtime rapid-acting insulin analogue or the substitution of a premixed insulin should be recommended. • Adding the injectable agent exenatide or another oral agent to this patient’s medication regimen is unlikely to reduce his hemoglobin A1c value sufficiently. When added to a combination oral regimen, exenatide has been shown to reduce hemoglobin A1c values by only 1% and the oral agents pioglitazone and sitagliptin by 1% or less. • In most studies of patients with diabetes, increasing the sulfonylurea dosage beyond the half maximal dosage has resulted in little to no improvement in glycemic control. Therefore, doubling this patient’s dosage of glipizide is unlikely to be effective.
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