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32-Year-Old Female Diagnosed with Type 2 Diabetes

Maria is 32 and was recently diagnosed with Type 2 Diabetes (T2D). Her recent symptoms include frequent urination, thirst, and irritability.

Her family history includes that her father was diagnosed with T2D when he was 56 and was on oral medication for several years before requiring insulin. In the past year, she relates that she has gained weight and experienced several yeast infections. She has a history of gallstones.

Her fasting lab results include:

A1C = 9.4
Glucose = 220
Urine microalbinuria/Cr ratio = 12 mg/g
eGFR = 86 mL/min/ m2
ALT = 59 IU/L
C-peptide = 4.3 ng/mL
Maria begins taking metformin, with the dose titrated to 2,000 mg daily. The fungal infection beneath her breasts is treated, and she is referred to a diabetic educator and sent for a full dilated funduscopic exam.

Maria returns in three months for evaluation. Her A1C has decreased to 7.7, and she has lost almost 10 lbs. Her eye exam is negative for retinopathy.

What second agent would you add to metformin?

  • from PA Unite 1 week 1 day
    Not enough information on this patient. What was her initial BP? Weight? Height? BMI? And what are those values on first follow-up visit? What is her repeat liver panel? Lipid panel? Was a thyroid panel done? What did her physical exam show? Did she have an enlarged liver? Does she show signs of PCOS? What does her glucose log look like? In particular, what have her blood sugars been since she has been on current dose of Metformin? Does she have any side effects from the Metformin? Does she have any other comorbidities? Did her father or any other first degree relative have early heart disease? She has lost 10 pounds and dropped her A1C almost 2 points on titrated Metformin. How long has she been on the current dose? What changes, if any, has she made to lifestyle? Why with a significant drop in weight and A1C after only three months of monotherapy do you think that she needs a second medication now? I would like the answers to these questions and another three months of monotherapy before considering a second medication.
  • 3 weeks 1 day
    Add januvia 100 qd
  • from Endocrinologist Nation 1 month
    I would try GLP-1 ( Trulicity or Victoza or oral Rybelsus if she refuses injectables); would get a Fibroscan; had repeated yeast infections and I would stay away from SGLT2i at least initially and if eGFR not improving , I would add it
  • from Endocrinologist Nation 1 month
    I would add a GLP-1R agonist to the metformin for several reasons including overweight and positive effect of this class of drugs on cardiovascular events as she has several factors stimulating CV disease
  • from Endocrinologist Nation 1 month
    I’d try Ozempic or Trulicity, these medications can be beneficial for obese pts and for pts with fatty liver. She needs additional work up for elevated LFTs, these should include RUQ abd US