Clinical Case: 47 Year-Old Clerk


Patient Background

47 year-old African-American woman with three children and one unsuccessful pregnancy. She has a full-time clerical job for a transportation company. On her last pregnancy five years ago, she had gestational diabetes. No other significant history.

She returns for her annual check-up. Her lab tests were drawn pre-visit.

Clinical Profile

Gender: Female
Age: 47
Weight: 192 lbs.
Height: 5’ 4"
BMI: 33

Glucose Monitoring
Last A1C: 8.5%
Fasting: 235 mg/dL

Lipid Profile
Total: 215 mg/dL
LDL: 135 mg/dL
HDL: 53 mg/dL
Triglycerides: 130

Kidney Profile
Creatinine: 0.9 mg/dL
Microalbuminuria: none

Liver Function
ALT: normal
AST: normal

Blood Pressure
Normal: 126/78 mmHg

Cardiovascular condition
within normal limits

Eye Exam

Foot Exam
Normal pulses and sensation


Compliance with meal plan?
Does not follow any specific meal plan. Interview reveals that she tends to cook
a high-fat diet with a large amount of
fried foods.

Compliance with exercise plan?
Does not exercise regularly.

Current Medications

For blood glucose: none
For other conditions: none

African-American women are at higher risk for type 2 diabetes. Together with her gestational diabetes and obesity, type 2 diabetes is a strong likelihood.

The American Diabetes Association recommends repeating the fasting blood glucose to confirm the diagnosis of diabetes. Some physicians faced with a patient who has an elevated A1c and high blood glucose may choose to initiate therapy without repeating the lab tests.

How would you initially treat this patient?
1)Diet and exercise alone
2)Diet and exercise plus an oral agent
3)Diet and exercise plus an incretin mimetic
4)Diet and exercise plus insulin


Diet and exercise plus an oral agent


Preferred answer: Diet and exercise plus an oral agent

This patient is judged to be in “fair control” (see Table 1). Her A1c is over 8% and her fasting blood glucose is 235 mg/dL.

She should receive instruction on nutrition and exercise, and should receive an antihyperglycemic agent to lower her blood glucose.

Table 1: Initial Control

Details of Initial Therapy

After meeting with a diabetes educator for one hour, the patient is judged to be capable of self-management. She will receive 10-15 more hours of diabetes education.

Goals of A1c less than 7% and/or mean plasma glucose less than 130 mg/dL are set, to be achieved within 4 months. The patient signs a contract.

She is started on metformin 250 mg bid, a 1200 calorie meal plan and self-monitoring of blood glucose twice a day. The patient is taught how to use the averaging function of the blood glucose meter.

Metformin can lower both fasting and postprandial blood glucose in people with type 2 diabetes. Its pharmacologic mechanisms of action are different from other classes of oral antihyperglycemic agents.

Metformin decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization.

Metformin monotherapy does not produce hypoglycemia in either patients with type 2 diabetes or normal subjects (except in special circumstances, see package insert PRECAUTIONS) and does not cause hyperinsulinemia.

With metformin therapy, insulin secretion remains unchanged while fasting insulin levels and day-long plasma insulin response may actually decrease.

Patient receives written instructions that in 2 weeks, if her average blood glucose is above 130 mg/dL, she should increase her metformin dose to 250 mg tid. Two weeks after that, if her average blood glucose remains over 130 mg/dL, she can change to a maximum of 500 mg, bid.

Patient will return in 10 weeks for evaluation.


Patient Assessment, Week 10

A1c: 7.4%

Weight: lost 5 pounds

Although she has made progress, patient seems to have stabilized at a blood glucose level of 160 mg/dL

The metformin dose is increased to 500 mg tid

The patient is instructed to self-increase the dose to 1000 mg bid if her average blood glucose values remain above 130 mg/dL

Schedule patient for follow-up visit in 8 weeks

Patient Assessment, Week 18

A1c: 7.2%

Weight: lost 2 more pounds

Patient has stabilized at a blood glucose level of 160 mg/dL. The higher metformin dose did not yield any additional efficacy.

Meal planning is hard for her but she has changed her eating habits. She has continued to lose weight, although one pound per month is slow.

Patient is amenable to additional therapy, and is able to pay additional medical costs.

At this point, would you:
1)Continue the therapy… it has made a difference
2)Add a second oral agent
3)Add exenatide
4)Add insulin

  1. Add exenatide

I think this is the best option


Preferred answer: add exenatide

Metformin alone has helped, but not enough. The physician wants to treat to target, and not accept sub-optimal therapy.

The decision options are:

  1. Add a sulfonylurea to the metformin therapy. It is the least expensive option.

  2. Add a glitazone, incretin mimetic or DPP4-inhibitor to the metformin therapy. These have low risk of hypoglycemia.

  3. Place the patient on insulin, which is the most effective therapy for lowering blood glucose.

This patient is able to manage the additional cost of exenatide, and the potential weight loss benefit is attractive.

Details of Therapy

Among the three non-insulin options, exenatide injection was selected because it is effective for lowering blood glucose and it facilitates weight loss.

Pramlintide (Symlin®) is only approved as an adjunct to insulin and is moderately effective for lowering blood glucose.

Sitagliptin (Januvia®) is relatively new. It is moderately effective for lowering blood glucose, and is weight neutral.

The patient is started on 5 micrograms (mcg) bid of exenatide using a pen and a 5mm pen needle. The exenatide should be stored in the refrigerator when not in use, but once an exenatide pen is in use, it can be stored at room temperature.

Possible nausea side effects of exenatide are discussed. The patient is told to self-increase the exenatide dose to 10 mcg in one month when her 5 mcg pen is empty, if little or no nausea is felt.

The metformin dose is reduced to 1500 mg per day.

Patient Assessment, Week 26

Patient’s A1c is down to 6.6%

Weight: lost 9 more pounds

Experienced some nausea on exenatide but was able to continue therapy.

Latest mean blood glucose is down to 125 mg/dL

Although the physician would like her A1c to be lower, her rate of weight loss and drop in A1c are gratifying, and her A1c is expected to continue declining.

Patient is praised for her success. Her goals for the next several months are discussed, and follow-up visits are scheduled at three-month intervals.


Diet, excercise and oral hypoglycaemic agent


diet exercise and oral drugs.


add second oral drug.


2)Diet and exercise plus an oral agent


Diet and exercise with oral agent


I would prescribe option 2 (diet, exercise, and an oral agent). The rationale being that she has an elevated HgbA1C, and she has had fetal macrosomia. Her diet is high is fat, and she also has an increased BMI. All of these factors influence my decision to start her on at least one medication. Thanks, Alan Doyle, D.O.


2Diet and exercise plus an oral agent


Diet and exercise plus an oral agent


Learned something! Thank you


It was very useful knowledge and information on Diabetes mellitus. Thanks, keep posting and sharing such illustrations.


Diet exercise and oral agent…