The patient, an active 49-year-old man, had an HbA1c of 8.6 after diabetes was first diagnosed. It’s now 7.6 with metformin and lifestyle measures. Is the current A1c goal adequate, or should you treat more aggressively?
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
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.