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VOLUME 1 ISSUE 5 CASE PD	PD is a 58-year-old woman who was diagnosed with Type 2 diabetes 8 years ago. She is employed as a marketing manager.
CHIEF COMPLAINT »  Unexplained weight loss »  Increasing fasting blood glucose CURRENT MEDICATIONS »  Glimepiride 4 mg/d »  Atorvastatin 20 mg/d PHYSICAL EXAMINATION »  Height: 5'10" »  Weight: 165 lbs »  BMI: 23.7 »  Blood pressure: 118/78 »  Pulse: 84, regular LABORATORY VALUES »  Fasting glucose: 168 mg/dL »  HBA1C: 9.2% »  LDL-C: 106 »  HDL-C: 55 »  Triglycerides: 152 mg/dL NAVIGATION »  Q1: What explains PD’s lack of response to metformin? »  Q2: What is the explanation for the change in PD’s formerly stable condition? »  Q3: What would you do now? Should antibody levels be measured? »  Q4: How would you initiate insulin in this patient? »  Q5: What effect will PD’s weight have on her insulin requirements? »  Q6: What is the primary difference among marketed insulin products? »  Q7: Would you select an intermediate- or long-acting insulin for PD as her basal insulin? »  Q8: What is your starting dose? »  Q9: What is the role of oral agents in nonobese patients with type 2 diabetes? »  Q10: Metformin did not work before in this patient, and her predominant physiologic defect is beta cell dysfunction. Why would you consider metformin, which primarily improves insulin utilization in the liver, now? »  Q11: What is the purpose of adding a TZD, which improves insulin resistance in muscle and adipose tissues, if this patient’s primary defect is insulin secretion, not insulin resistance? »  Q12: At what times should PD be instructed to monitor her blood glucose levels? »  Q13: What can you do to encourage a reluctant patient to accept the fact that insulin therapy is needed? »  Q14: What symptoms of hypoglycemia should you warn about? »  Q15: How should PD be instructed to manage any symptoms of hypoglycemia before calling you?	Q: What is the primary difference among marketed insulin products? A: The main differences among the available insulin preparations are time of onset and duration of action (Table 1).5-7 Insulin is available in rapid-, short-, intermediate-, and long-acting formulations that may be injected separately or mixed in the same syringe. Rapid-acting insulin analogs (insulin lispro and insulin aspart) are available, and other analogs are in development. Regular is a short-acting insulin. Intermediate-acting insulins include lente and NPH. Ultralente and insulin glargine are long-acting insulins. Insulin preparations with a predetermined proportion of intermediateacting insulin mixed with short- or rapid-acting insulin (eg, 70% NPH/30% regular, 50% NPH/50% regular, and 75% NPL/25% insulin lispro) are also available.7
	Questions? Contact 1-888-JEFF-CME (533-3263) or http://jeffline.jefferson.edu/jeffcme
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