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.