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Paul is a 41-year-old Caucasian who was diagnosed with Type 2 diabetes 4 years ago. He is a high school teacher. His initial treatment began with 500 mg of metformin twice daily. A year later, the dosage was increased to 1000 mg twice daily. The glucagon-like peptide 1 (GLP-1) receptor agonist liraglutide was added about a year ago to gain better control.

The patient’s A1C remained below 7.0% until now. His fasting blood glucose level has increased from around 125 to 160. He eats a high-fiber, low-fat diet, walks 30 minutes about 5 days a week, and gets 7-to-8 hours of sleep nightly. His blood pressure is 130/80 mm Hg with a heart rate of 70. However, his BMI is 31.4.

His medication regimen is:

Metformin, 1000 mg twice daily
Liraglutide, 1.2 mg daily
Lisinopril, 20 mg daily
Atorvastatin, 20 mg daily
His A1C has risen to 7.8%.

What factors should be considered now that Paul’s Type 2 diabetes has become poorly controlled? What would be your treatment plan for this patient?

  • 1 week
    What is his current BMI ? What was his BMI in the oast one year .Also check his compliance with diet and exercise .

    I wound recommend follow up with a nutritionist , and recom regular exercise and add SGLT2 to lower A1c, as well to obtain the other benefits of SGLT 2- (CV ,renal benefits)

    .I would get labs -c pep, anti islet ABs, insulin level to check if he has become type 1 ?
    I would rechk his PBG and FBG in 2 wks time to see if all the above has improved his numbers .

  • from Pharmacist Society 1 week 1 day
    I'm concerned that he is not exercising enough or at a intensity level that high enough for him. I think he is probably going to need some counseling on his diet and current medication regimen. I think Metformin or a SLGT2 would help get his A1c down as well.
  • from Generation NP 1 week 1 day
    What was his prior weight? Has he lost weight? I would reinforce diet and exercise. In addition I would consider how he is taking his meds. Also it would be helpful to have post prandial BS. If all that is already maximized then consider adding a GLP1 or increasing his current medication to 1.8
  • from Endocrinologist Nation 1 week 2 days
    More likely benefit from seeing his BS after certain meals. Adding SGLT2 would be useful as well, but I would first get a diet lower in carbs and get him walk at least 6 days a week, 30 min, even if that is split ( 15 min bid)
    A fit bit monitor would help him more encouraged, or GET A DOG!
  • 1 week 2 days
    Would add a SGLT2 and/or basal insulin. Would evaluate his lifestyle and promote weight loss and exercise. He would be a candidate for a CGM for a few weeks to monitor his glucose. It is not clear as to what his needs are at this time
  • from Pharmacist Society 1 week 2 days
    I would start off by increasing the liraglutide to 1.8 mg that will probably further decrease his BMI. If that doesn't work then I will add a SGLT inhibitor. If there no improvement then I will suggest Insulin.
  • 1 week 3 days
    Would give trial swithing to Rybelsus and if needed add SGLT
  • 1 week 3 days
    His Weight control will be very helpful in this case, he has to do go on very low carbohydrate diet and try to lose weight.
  • from Pharmacist Society 1 week 3 days
    Maximize GLP1 agent by either increasing liraglutide to 1.8mg daily or switch to simaglutide 1mg weekly if tolerated but might need to start with 0.5mg and increase as able. Focus on diet and exercise. Consider CGM for patient awareness of how lifestyle choices might be affecting BG. if next A1c still >7 consider SGLT2.
  • 1 week 3 days
    An SGLT2 or if concerned about too much weight loss..toujeo or tresiba
  • 1 week 3 days
    I MRI the abdomen to start.
  • from Endocrinologist Nation 1 week 3 days
    Continued diet with aim for weight loss. Common mantra is SGLT-2 but since fastings are high pio is the best answer. Would also change to sema vs lira.
  • from Endocrinologist Nation 1 week 3 days
    Continued diet with aim for weight loss. Common mantra is SGLT-2 but since fastings are high pio is the best answer. Would also change to sema vs lira.
  • from Endocrinologist Nation 1 week 3 days
    Continued diet with aim for weight loss. Common mantra is SGLT-2 but since fastings are high pio is the best answer. Would also change to sema vs lira.
  • 1 week 3 days
    Since he is on the right meds.. Adjusting his GLP I with higher dose, educating and counseling for the low carb diet, may be Keto diet and encouraging guiding for the exercise, food diary etc would have a better chance to improve his diet and also weight loss. losing even 5 % of his weight with all these measures itself will have significant impact on his health, weight and sugar.
  • from Generation NP 1 week 3 days
    I would increase the liraglutide, encourage healthy diet/choices, encourage exercise and consider trulicity down the road if other interventions not effective.
  • 1 week 3 days
    Regular exercise and proper diet will be a great choice to prevent diabetic complications.
    I will recommend to add
    Lantus 10 u twice daily.
  • 1 week 3 days
    BP is borderline, weight high, Metformin and a GLP-1 are a good start. Would add a SGLT-2 such as Farxiga 10 mg daily and work on diet and exercise to achieve IBW.
  • 1 week 3 days
    It sounds like this is a motivated patient who has had some success. I would congratulate him on the work he has done so far. I would also share that T2D is a progressive condition and adjustments in treatment are common over time. I would like a bit more detail on his current therapeutic lifestyle behaviors and make sure they are adjusting with his level of fitness. I encourage him to get at least 14 grams of fiber/1000 kcal daily and consider the carb content of his food. He is on max effective dose of metformin but not the max daily dose of liraglutide. He could increase to 1.8 mg, alternatively with the once weekly GLP-1 semaglutide and high dose (3 and 4.5) dulaglutide he could get additional A1c benefit. Alternatives could include a SGLT-2I or basal insulin. While it may not be the focus of this case h could also consider metabolic (weight reduction) surgery as it too can dramatically improve weight and A!c.
  • from Generation NP 1 week 3 days
    Diet, exercise, dietary diary, cont present meds, add sglt2, if not on adequate dose of glp, increase.
  • 1 week 3 days
    The best approach to his worsened control (assuming compliance with his current meds) is to stress the lifestyle changes. Loss of only ten pounds plus regular aerobic exercise would probably drive the HgA1c down to <7.0. I would continue the metformin and liraglutide; if the liraglutide is tolerated well from a GI standpoint, consideration might be given to increasing the dose to 1.8mg daily. If these interventions are not reasonably successful within a few months,I would probably add a SGLT-2 inhibitor. I certainly would continue the atorvastatin and lisinopril unless there are problems related to them.
  • 1 week 3 days
    Diet, exercise, weight reduction are still indicated. I would continue with metformin and the GLP-1. I would add an SGLT-2, typically Jardiance 10 mg a day. This should lower his A1c, help with weight loss and help with CV and CKD risks in the future
  • 1 week 3 days
    The rise of the Fasting Blood glucose and the eventual rise of the Hba1c relfects most likely PP glucose rise after dinner or the nocturnal hepatic glucoeneogenesis it also reflects the declning Beta cell fucntion and the GLP-1 has been on board for the last 4 years and has done its job and now it is the time to revisit the other options but most improtantly needs to montior the PP glucose after dinner and a CGM analysis will be helpful and if it is high control the caloric intake before the dinner and increase the physical activity after dinner like 20 minutes of walk ! The other pharmaceutical intervention that could be applied would be the addition of the SGLT 2 inhibitor and metformin could be replaced with Glyxambi which is the combo of metformin and the Jardiance to simlify the meds A c-Peptide level can be done to see how the Beta cells are doing and the need for the insulin down the road !
  • 1 week 3 days
    I would check his TSH if not already done. He would likely benefit by dietary counseling, subscription to Nutri-System, etc. One inexpensive addition would be psyllium capsules such as Yerba Prima Veg Caps, widely available, 5 twice a day which lower cholesterol slightly as well as giving a feeling of fullness and appetite suppression. I would certainly consider adding SGLT2 inhibitor if affordable to lower A1C, cardiac risk, and weight. At next A1C check, if weight hasn’t improved, consider a course of lorcaserin or other relatively safe prescription weight-loss medication.
  • from Generation NP 1 week 3 days
    There are so many other stressors that affect elevations in blood sugar, with a sudden change I would be looking at what new stressors are affecting his life and work on these first before changing up or adding insulin which is also going to increase his weight gain. Consider using a different GLP-1 and give a little more time to make some adjustments and work on stressors. It doesn’t matter if AIC goes up and nothing is done to address what the cause may be you are not going to make any progress in the long term of AIC control.
  • 1 week 3 days
    Review diet, medication and lifestyle regimen, refer to diabetic educator/nutritionist. Just because he is eating a low fat, high fiber diet, that doesn’t mean he is not eating too many calories per day. Increasing liraglutide can help with weight loss. He is obese and must lose weight.
  • from Endocrinologist Nation 1 week 3 days
    I don’t believe there is any reason to suspect type 1 DM. Deterioration in glycemic control is either due to change in lifestyle particularly diet, or natural progression of type 2 diabetes with declining beta cells function.
    Adding insulin at this stage with A1C of 7.8 is unnecessary and will likely cause additional weight gain in an obese patient.
    I would refer for nutritional counseling and consider adding a SLGT2 inhibitor, which will get his A1C below 7 with an additional benefit of modest weight loss and cardiovascular risk reduction.
  • 1 week 4 days
    first,i would like to know if he is type 1 or type 2 diabetic , by doing antibodies e.g GAD
    depending on that, iwill know if he is insulin dependant or not
    second, assuming that the antibodies tests indicate Type 2 Diabetis,., he is still overweight inspite of excellent diet and exercise habits and Liraglutide. So he needs more aggresive maneuvers, to loose weight ,personally by suggesting Bariatric surgery (or medications).
  • 1 week 4 days
    perhaps he is eating school lunches and breakfasts??? Maybe checking PPG and adding Precose with meals would lower his HbA1C??
  • from Generation NP 1 week 4 days
    Before you ask Paul to change anything you need to have him identify what he thinks has changed in his life that might have contributed to his rise in A1C. Perhaps he lost his job and insurance. You cannot assume he has been able to maintain his regimen during the pandemic. After helping him identify what has changed, then make medication or lifestyle recommendations. Remember only a little at a time for best results.
  • 1 week 4 days
    What is patient life style and BMI? he is taking max dose of metformin and on a weekly GLP-1, I would consider either a DPP4 to lower his HgA1c 0.5 % to almost goal of 7 %. May be a SGLT-2 such as Dapa or Empa with additional benefit beyond diabetes control, such as cardiovascular and renal protection from recent data.
  • 1 week 4 days
    I suspect this patient may actually have type 1 diabetes with partial islet preservation for now. I suggest checking for anti islet antibodies, insulin levels, and also a C peptide level to see if he is deficient with islet autoimmunity. If he has this problem, the only answer to his conundrum would be insulin.
  • from PA Unite 1 week 4 days
    I would recommend starting seeing a nutritionist. As medication, i would start considering insulin, reason why it is never too early to initiate the discussion with the patient and starting the education process, which i believe accounts for half of the treatment.
  • from Pharmacist Society 1 week 4 days
    Sam Gurevitz I would confirm with the Paul is still walking 30 minutes 5 days a week. Could ask Paul to increase his exercise intensity. Inquire about his diet. Talking to a dietician might be helpful. Suggest seeing a dietician. I would consider increasing liraglutide to 1.8 mg subcutaneously once a day.
  • 1 week 4 days
    Evaluate diet exercise plans. Possible change meds to trulicity and metformin. Needs cardiac evaluation
  • from Generation NP 1 week 4 days
    Increase the liraglutide to 1.8mg SC daily or add an SGLT2 inhibitor. I would also refer to a nutrition counselor to make sure he is eating a recommended ADA diet. In fact before starting any other medication diet may be something worth investigating a little closer.
  • from Generation NP 1 week 4 days
    GLP1's work very well - what you have to consider is changes in the patient's lifestyle/ eating/exercise habits . For example with covid quarantine many of my patients have stopped exercising because they can't go to the gym and are eating more because of staying home - If these have not changed then blood work to determine pancreatic insulin function may be considered. Medication wise the next step may be an SGLT2
  • 1 week 4 days
    Obviously, he falls into the obese category with his BMI. Paul needs to increase exercise intensity and check to where his diet needs modification. A dietician/nutritionist would help. A GLP-1 receptor agonist like Rybelsus would help for his diabetes and weight control.