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Case Study: Uncontrolled Type 2 Diabetes

By Kevin O. Hwang, MD, MPH

Reviewed by Clifton Jackness, MD, Attending Physician in Endocrinology, Lenox Hill Hospital and the Mount Sinai
Medical Center, New York, NY

A 45-year-old woman with type 2 diabetes arrives for a follow-up visit 1 week after her HbA1c was
determined. She has been compliant with metformin 1000 mg twice daily. She reports that her home
blood sugar readings have improved slightly but are still high. She admits to a few dietary
indiscretions, such as having multiple servings of dessert when going out with friends. For exercise,
she has been walking 10 to 15 minutes a day.
She denies polyuria, polydipsia, or blurry vision. The review of systems is unremarkable.
Her medical history is significant for:

Type 2 diabetes, diagnosed 6 months ago when she presented with polyuria, blurry vision,
and a random glucose level of 276 mg/dL. Her HbA1c at that time was 8.0%. She was started on
metformin 500 mg twice daily, and within 3 months her HbA1c dropped to 7.6%. The metformin was
increased to 1000 mg twice daily at that time. She has not had significant hypoglycemic episodes.
Hypertension, treated with lisinopril 40 mg daily.
Dyslipidemia, treated with atorvastatin 20 mg daily.
Esophageal reflux treated with omeprazole 20 mg daily.
Vital signs are blood pressure 122/76 mm Hg, heart rate 82, respiratory rate 18, temperature 98.1 F,
height 55, weight 196 pounds, and BMI 32.6. She has not gained or lost significant weight since
she started treatment for diabetes.
On exam, the lungs are clear to auscultation, the heart has a regular rate and rhythm without
murmurs, and the abdomen is nontender. Peripheral pulses are normal, and there is no lower
extremity edema. The foot exam shows normal sensation to light touch and no skin or toenail

HbA1c level, determined last week, is 7.3%.

Patients blood glucose log shows morning fasting glucose ranging from 120 mg/dL to 150
mg/dL, and postprandial readings at 190 mg/dL to 220 mg/dL.
Targets for Diabetes Control

The American Diabetes Association (ADA) recommends a target HbA1c of less than 7.0%, fasting
glucose less than 130 mg/dL, and postprandial glucose less than 180 mg/dL for most patients. 1 A
more ambitious HbA1c target of 6.0% to 6.5% may be appropriate for patients with a long life
expectancy and no cardiovascular disease, provided that this can be achieved without adverse
effects, such as severe hypoglycemia. On the other hand, a target HbA1c of 7.5% to 8.0% may be
suitable for patients with significant comorbidities, limited life expectancy, and a history of severe
hypoglycemia. This goal is also reasonable for patients who have not been able to reach lower
HbA1c levels with multiple diabetes medications and extensive education about diabetes selfmanagement. Given our patients overall health profile, her target is an HbA1c level of less than
7.0%, or eventually even 6.0% to 6.5%.
The patients HbA1c has improved since starting metformin, but is still not at target. Her fasting and
postprandial glucose levels are also too high. The underlying causes for hyperglycemia in this
patient include dietary factors, inadequate exercise, and obesity. She has no signs or symptoms of
an acute illness that could cause hyperglycemia.
The maximum recommended dose of metformin for adults is 2000 to 2500 mg daily, depending on
the formulation. Her current total daily dose is 2000 mg, and it is unlikely that her glycemic control
will improve significantly just by adding another 500 mg of metformin.
The patient is referred to a diabetes education and support class. She is briefly counseled on
lifestyle changes to improve her diet and increase her physical activity. Diabetic individuals in the
intensive lifestyle intervention arm of the Look AHEAD study lost 8.6% of their weight in the first year,
with an average reduction in fasting glucose from 152 mg/dL to 130 mg/dL and reduction in HbA1c
from 7.3% to 6.6%.2 If a similarly intensive program is available, this patient should be referred to it.
If HbA1c is not in the target range on metformin alone (as in this patient), an additional medication
would be beneficial. Many options are available, but the ADA recommends choosing one of the
following agents in most cases:
Glucagon-like peptide (GLP)-1 agonist
Dipeptidyl peptidase (DPP)-4 inhibitor
A number of issues should be considered when choosing between these medication classes,
Patient preference for route of administration and other factors
Efficacy in reducing HbA1c
Potential to cause hypoglycemia
Potential to induce weight gain
Side effects
Our patient is agreeable to adding another diabetes medication but does not want to use an
injectable medication. Since she is obese and has not been losing weight, an important
consideration would be to avoid inducing further weight gain. After starting the second medication

and working on lifestyle changes, a repeat HbA1c test and follow-up appointment is arranged for 3
Published: 02/24/2015

Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patientcentered approach: position statement of the American Diabetes Association (ADA) and the European
Association for the Study of Diabetes (EASD). Diabetes Care. 2012;35:1364-1379.
Look AHEAD Research Group. Reduction in weight and cardiovascular disease risk factors in individuals
with type 2 diabetes: one-year results of the Look AHEAD trial. Diabetes Care. 2007;30:1374-1383.


Patient Background
54 year old male lawyer has had high blood glucose for
over a year, but only now after a random reading exceeds
300 mg/dL on an office visit is he willing to admit that he
has diabetes.
He has had a previous heart attack and is taking several
cardiovascular and hypertensive medications.
His physical exam today is normal. He has a BMI of 28.
He admits to feeling a little tired, recently, and has been
getting up at night to urinate at least two to three times
per week.

Age: 54

Lipid Profile

Liver Function

Weight: 212 lbs.

Total: 153 mg/dL

ALT: normal

Height: 6' 1"

LDL: 70 mg/dL

AST: normal

BMI: 28

HDL: 41 mg/dL

Blood Glucose

Triglycerides: 225 mg/dL

Blood Pressure

Last A1C: 10.2%

Kidney Profile

Normal: 130/90 mmHg

Creatinine: 0.8 mg/dL

Fructosamine: 429 mmo/L
(nl <250)


condition Previous


myocardial infarction

Eye Exam
Foot Exam
Normal pulses and
Random: 358 mg/dL

Compliance with meal plan?

No diabetes meal plan at this time.


Compliance with exercise plan?

Limited activity and rare exercise.

For other conditions:

HCTZ, 25 mg qd
For blood glucose: none

Metoprolol (Toprol XL), 50 mg qd

Aspirin 81 mg qd
Simvastin (Zocor) 20 mg qd