Q: Mr Jones is a 49-year-old man with type 2 diabetes mellitus diagnosed 18 months ago. Treatment with metformin, 2500 mg/d, was started. His HbA1c was 8.6 initially: it’s now 7.6. His BMI decreased from 35 to 32 with lifestyle changes. Should I be any more aggressive with him or is the current A1C goal adequate?
Dr Shahady: Does Mr Jones have any microvascular or macrovascular complications of diabetes?
|Newly Diagnosed Type 2 Diabetes Mellitus|
Newly Diagnosed Type 2 Diabetes Mellitus
Q: He has no evidence of eye disease, renal disease or neuropathy, or cardiovascular events.
Dr Shahady: Is he active and has he the resources to provide self-care?
Q: He plays tennis 4 or 5 times a week. He has good insurance coverage, has a supportive family, and has learned a lot about his diabetes since his diagnosis.
Dr Shahady: With no evidence of complications, a good support system, adequate insurance, capacity to self-manage, and recent onset of diabetes, I would be more aggressive with him. I would try to get his HbA1c as close to 6 as possible.
The UKPDS trial with patients who had recent-onset diabetes demonstrated a decrease in both microvascular and macrovascular complications with more aggressive early management. More recent trials, such as the ACCORD,1 VADT,2 and ADVANCE,3 demonstrated effectiveness and safety for a lower A1c in younger patients with no microvascular and macrovascular complications and diabetes of less than 10 to 15 years’ duration. Safety is important with aggressive treatment, so I would choose medications carefully and monitor his progress with frequent follow-up and good self-management.
Q: What medication would you use?
Dr Shahady: I would have used 2 medications initially because of the A1c >8. One oral agent usually will reduce the A1c about 1%. I’d add another oral agent or a GLP-1 receptor agonist. Adding a sulfonylurea such as glipizide or a glitizone such as pioglitazone will provide an additional decrease of 1% but both can produce weight gain, and hypoglycemia is a problem with the sulfonylurea.
A DPP4 inhibitor such as sitagliptin or saxtagliptin will produce about a 0.5% reduction in A1c and is weight-neutral. A GLP-1 receptor agonist will provide about a 1% drop in A1c and weight loss but must be injected.
If cost is an issue, a sulfonylurea is least expensive. Since the patient has good insurance coverage and his BMI is 32, I would opt for a GLP-1 receptor agonist such as exenatide (bid or once weekly) or liraglutide.
1. The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358:2545-2559.
2. Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009;360:129-139.
3. The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358:2560-2572.