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Q: What is your overall approach to the management of JJ’s problems?
A: Diabetes control must be optimized. The persistent hyperglycemia, despite maximal doses of sulfonylurea and metformin therapy, mandates additional action. Lifestyle intervention should be reinforced; in addition, a trial of an insulin sensitizer (thiazolidinedione) as a third oral antidiabetic agent is a consideration. Alternatively, basal insulin therapy can be instituted at bedtime and titrated, while continuing the oral agents. The dose of fosinopril should be increased to 40 mg QD to determine whether microalbuminuria can be suppressed further. The dyslipidemia warrants consideration of early use of hypolipidemic agents (eg, HMG-CoA reductase inhibitors) as adjuncts to dietary therapy. Finally, JJ should be monitored for diabetic complications on a regular basis.15,16
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