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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?

 Does Mr Jones have any microvascular or macrovascular complications of diabetes?

He has no evidence of eye disease, renal disease or neuropathy, or cardiovascular events.

 Is he active and has he the resources to provide self-care?

 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.

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,

 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.

 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. 

http://www.nejm.org/doi/pdf/10.1056/NEJMoa0802743


2. Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veterans with type 2 diabetes. 

http://www.nejm.org/doi/full/10.1056/NEJMoa0808431


3. The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. 

http://www.nejm.org/doi/full/10.1056/NEJMoa0802987

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?

Man With Newly Diagnosed Type 2 Diabetes: What HbA1c Goal-And How to Get There?

70-Year-old Mrs Smith has a 7-year history of type 2 diabetes. Her medications include glipizide, 2.5 mg a day, and lisinopril, 10 mg a day. She weighs 175 pounds and her BMI is 30. Her HbA1c is 7.5 and her blood pressure 130/80. Recently she has experienced 2 episodes of dizziness and her blood sugars were 50 and 55. 

 I was surprised that her blood sugars were so low with an HbA1c of 7.5. Does that surprise you?

  I also have had similar patients. Remember that HbA1c reflects the average blood sugar for the last 2 to 3 months. So an HbA1c of 7.5 probably means a mean plasma glucose of about 170; but this number doesn’t tell us the about the variability or swings in daily glucose levels. This patient probably has daily drops below 70 and post meal increases to 200 plus to give her a mean blood sugar of roughly 170.

  What do you suggest for this patient? 

  We usually think of hypoglycemia in patients taking insulin or a sulfonylurea but it can occur for reasons other than medication. For example, as patients  age, their eating habits change. This patient may be eating erratically. Excessive alcohol ingestion, chronic renal disease, and poor sleep habits are other factors. About 42% of type 2 diabetes patients experience hypoglycemia, but it is usually mild (>50). 

For this patient’s management, I would stop the glipizide and obtain a creatinine and GFR. If her GFR is > 60, I would start metformin. If her GFR is lower, I would consider using a DPP4 inhibitor or GLP-1 receptor agonist that has limited renal clearance. Linagliptin, a DPP4 inhibitor, and liraglutide, a GLP-1 receptor agonist, are good options in patients with lower GFRs and higher creatinine.

Don’t forget to discuss the other possible causes of hypoglycemia like skipped meals and excessive alcohol ingestion. A tip to overnight hypoglycemia would be nightmares and night sweats. If the patient wakes up in the middle of the night, ask her to check her blood sugar.

  Are future episodes of hypoglycemia a concern?

Yes-prior hypoglycemia is a predictor of future hypoglycemia. More frequent self-monitoring of blood sugar should help.

Hypoglycemia in type 2 diabetes patients can be the result of insulin or sulfonylureas.

Challenging Case: A Patient With Hypoglycemia and High HbA1c

Bariatric surgery nearly cures type 2 diabetes-at least that’s what results of a new study seem to imply. The study, presented at the recent American College of Cardiology meeting and published in the 

 found that among 150 patients with type 2 diabetes and average BMI of greater than 27, 42% of those randomly assigned to the stomach-reducing surgery quickly reached blood sugar targets and remained controlled at 1-year follow-up.

What’s more, the use of medications to reduce glucose, lipid, and blood-pressure levels decreased significantly after both surgical procedures, but increased slightly in patients receiving medical therapy only. There were no severe complications.

What do the study results tell us about medical management of type 2 diabetes? What are the dangers, if any, associated with bariatric procedures? And, which patients with type 2 diabetes would be candidates for these procedures?

Here to put this issue into perspective are Drs. Deepak Bhatt, Christopher Cannon, and Payal Kohli. Dr Bhatt is chief of cardiology for the VA Boston Healthcare System, a senior investigator with the TIMI Study Group, and associate professor of medicine at Harvard Medical School. Dr Cannon, a senior investigator with the TIMI Study Group, editor-in-chief of 

 and a professor of medicine at Harvard Medical School. He is also an associate physician in the Cardiovascular Division of Brigham and Woman’s Hospital in Boston. Dr. Kohli graduated from Harvard Medical School and completed her internal medicine training in Boston and is scheduled to start her fellowship in cardiovascular medicine at the University of California San Francisco in June 2012.

Bariatric surgery nearly cures type 2 diabetes-at  least that’s what results of a new study, presented at the recent ACC meeting, seem to imply.  

Podcast: Bariatric Surgery Bests Medical Therapy Alone in Obese Patients with Diabetes

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