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.
Weight: 192 lbs.
Height: 5’ 4"
Last A1C: 8.5%
Fasting: 235 mg/dL
Total: 215 mg/dL
LDL: 135 mg/dL
HDL: 53 mg/dL
Creatinine: 0.9 mg/dL
Normal: 126/78 mmHg
within normal limits
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
Compliance with exercise plan?
Does not exercise regularly.
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