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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 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? A: As is the case with metformin, TZDs do not work effectively when there is insufficient insulin present. However, when used in combination with insulin, rosiglitazone and pioglitazone further lower fasting glucose levels by 30 mg/dL to 50 mg/dL and HbA1c levels by 0.5 to 1%.9-10 Allowing insulin to work more effectively can also lower insulin requirements. The use of metformin or TZDs should be monitored closely in this type of patient, and if oral therapy does not improve PD’s overall control, it should be discontinued, and insulin should be used alone.
	Questions? Contact 1-888-JEFF-CME (533-3263) or http://jeffline.jefferson.edu/jeffcme
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