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May 08, 2021

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?

  • May 08, 2021
    Maria needs to start with nutrition. For her T2DM I would get a formal diabetic educator consult. She needs to work with an exercise program and weight reduction. She is maximized on Metformin. It would be nice to know her blood pressure and lipid profile. Does she have a blood sugar log- her A1C is definitely better, but not ideal given her young age. I am worried by the elevated liver transaminase and assume that she has NASH. I would prefer adding in a GLP-1. I have had tremendous success with tolerance to Ozemic/ Trulicity/ Rybelsus as long as her insurance will cover. This could help with her A1C and weight.
  • April 28, 2021
    C-Peptide levels at elevated, I would highly recommend nutrition consult, Give her an exercise prescription, recommend she read the book The Obesity Code by Jason Fung MD. I would work up the Gallstones and r/o Fatty Liver and if present monitor liver enzymes closely for NASH. If I had to add another class of meds I would go with GLP-1 agent. I would also work on getting her approved for a CGM such as Freestyle libre.
  • April 28, 2021
    can add DPP-4 inhibitor namely Januvia with the current regimen along with a Statin and low dose of ACE inhibitir.
  • April 28, 2021
    Definitely Ozempic/Trulicity weekly, not Farxiga/Jardiance/Invokana with yeast infection history. At 32 years, a long discussion on fertility/conception plans or risks is warranted as this could be a real issue especially if she gets under better glycemic control. Her chance of conceiving may improve, especially with the likely co morbid PCOS that would also occur with this clinical scenario. Even though metformin is not indicated for PCOS, it does seem to help with return from anovulatory cycles to more normal cycles so pregnancy risk is high
  • April 28, 2021
    Ozempic or another GLP-1 would help with the A1C
  • April 28, 2021
    I would add Ozempic weekly injections. It decreases A1C effectively and also decreases her weight by ~10 lbs.
  • April 28, 2021
    SGLT2 or GLP1 based on insurance coverage
  • April 28, 2021
    Victoza to help further with weight loss and control diabetes better. I will also pursue further work up for LFT - including RUQ US
  • April 27, 2021
    I would probably add Farxiga. Even though fungal infections can be a side effect of the SLTs, I think the fungal infections previously were probably due to her uncontrolled blood sugar. With the benefits of lower HgbA1C, projected weight loss, cardiovascular advantages, and tolerability, this makes Farxiga a wise choice.
  • April 27, 2021
    I would add Trulicity to the regimen (GLP-1) to help the patient achieve an A1C below 7% and to decrease other associated comorbid risk factors.
  • April 27, 2021
    Will add Zoe pic or rybelsus
  • April 27, 2021
    I would add a GLP-1. Ozempic or Trulicity. These would bring down the A1c continue with weight loss if she needs it since no weight is given. If the patient refuses injectable I would try Januvia. Need to continue to monitor A1C
  • April 27, 2021
    In light of her lifestyle improvements & response to metformin, could consider waiting before adding on a second agent.
    If a second agent is needed, would consider either a weekly GLP1 or Rybelsus of her insurance covers
  • April 27, 2021
    I would not add any new medications without further history. A drop in her A1C and weight is a good sign the therapy is working. More literature is discouraging providers from treating patients on A1C alone. However, if there are issues with her BP, BMI, metabolic profile, etc then I would consider adding an additional agent like a GLP-1.
  • April 27, 2021
    I would add GLP 1 agonist - Ozempic if covered and if not then try Rybelsus. Would monitor her LFTs and if needed obtain a Fibroscan.
    Start on ACE- I to protect the kidneys and microalbuniuria
  • April 27, 2021
    I would add a GLP-1 onto metformin. Improved post prandial coverage with weight loss potential.
  • April 27, 2021
    would like to know her BMI, if high would go with a GLP-1 for added weight loss and efficacy in lowering sugars. . With her current glucose control this should easily get her to goal.
  • April 27, 2021
    Would recommend a few things, would like to know if she is on a statin or ACE/ARB. Would benefit from ongoing exercise. Could choose from a few options, yes a GLP-1 is an option, but can also consider a DDP-4 or SGLT-2. Patient may benefit from a CGM if highly engaged /motivated. Would like to know more about the length of the metformin therapy. She may be doing well as is if her daily numbers continue to decline. Patient may not be able to afford the newer medication. Numerous factors at play. It is very easy to say GLP-1
  • April 27, 2021
    At this time, I would add on an SGLT-2 or even consider a DDP4 or GLP1 need to understand the cost to the patient. Patient should be continue to encourage diet as well as exercise. CGM may help motivate the patient to see improvement, again if covered by insurance
  • April 27, 2021
    I would add victoza or saxenda along with metformin to help lose weight along with diabetes control. Regular exercise program to keep her active and sustain
    The weight loss.
  • April 27, 2021
    I would recommend to add a GLP-1 and follow the A1C.
  • April 27, 2021
    Trulicity or Victoza will help weight as well.
  • April 27, 2021
    Given her age and hints of a weight issue, I would add Rybelsus. Usually well tolerated and should help decrease weight with the goal of minimizing medication; Any additional family history might sway me to add Jardiance instead
  • April 27, 2021
    I think she would benefit from a semaglutide such as Ozempic or Rybelsus. This would help bring her HbA1C level down and also weight loss. Studies have shown improvements with cardiovascular disease.
  • April 27, 2021
    Would add GLP, Victoza
  • April 27, 2021
    I would consider adding pioglitazone to address her diabetes and likely fatty liver causing the alt elevation
  • April 27, 2021
    I would second using a GLP1 agonist such as Trulicity. The efficacy is fairly high with a low side effect rate. There is the nice added benefit of weight loss as well. The main downside would be the high cost and issues with preauthorization and coverage etc.
  • April 27, 2021
    I might not add a second agent if she is motivated to lose more weight, and exercise in order to try to avoid the potential cost and side effects of a second med. She probably has nafld due to her dm, but this may resolve with better glucose control; would follow up on this. If needed, then a glp1 RA may help her lose more weight.
  • April 27, 2021
    I would try a Glp-1
  • April 27, 2021
    I would use a GLP-1 such as Ozempic or Victoza
  • April 13, 2021
    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.
  • March 30, 2021
    Add januvia 100 qd
  • March 22, 2021
    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
  • March 22, 2021
    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
  • March 19, 2021
    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