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Practical Strategies for Choosing Among Incretin-Based Agents in Type 2 Diabetes


Despite best efforts with lifestyle modification and adherence to metformin and glimepiride therapy, this man’s A1C continues to rise. What next?

Mark, a 55-year-old white man, received a diagnosis of type 2 diabetes 3 years ago. At the time of diagnosis, his glycosylated hemoglobin (A1c) level was 7.5%, his BMI was 30 kg/m2, and his waist circumference was 45 inches.

Initially, he was given metformin 500 mg twice daily, a diet with moderate caloric restriction, and an exercise regimen.

After 3 months, the metformin dosage was increased to 1000 mg twice daily. After 1 year of treatment, his A1c level was 6.7%; at 2 years, it had risen to 7.1%. Despite his best efforts with lifestyle modification and adherence to metformin therapy, however, Mark’s A1c level had recently risen to 8.4%. To regain glycemic control, he was given glimepiride, 2 mg daily, in addition to metformin.

His past medical history includes hypertension, for which he takes lisinopril, 20 mg daily, and dyslipidemia, for which he takes pravastatin, 40 mg daily. Recently, his blood pressure was 130/80 mm Hg and fasting laboratory results indicated an LDL cholesterol level of 150 mg/dL, triglycerides of 160 mg/dL, and HDL cholesterol of 40 mg/dL. He is a vice president of a marketing firm, travels frequently, and he is concerned about how the adverse effects of his medications, and their convenience, will fit with his busy work schedule.

Mark now presents 6 months after the addition of glimepiride, and has gained 3 kg since that time. His A1c level is 7.6%, and his fasting plasma glucose (FPG) is 142 mg/dL. He reports 3 episodes consistent with hypoglycemia in the past 3 months. One episode, which occured while Mark was flying for a business trip, required assistance from another passenger and the flight attendant. Mark is very concerned about his weight gain and the episodes of hypoglycemia.

Which of the following represents the most appropriate A1c treatment target for this patient according to clinical guidelines from the American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD)?

A. Less than 6.5%
B. Less than 8.0%
C. Less than 7.5%
D. Less than 7.0

The answer, and discussion, can be found at:


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