Clinical Case: 48 Year Old Bookkeeper


Patient Background

48-year old Hispanic woman comes to her doctor for recommendations about her weight.

She is married, has 2 children in school and works full time as a bookkeeper.

She eats breakfast and dinner at home, and buys lunch at various locations.

Clinical Profile

Age: 48
Weight: 178 lbs.
Height: 5’ 3"
BMI: 31.5

Glucose Monitoring
Last A1C: 8.2%

Fasting: 158 mg/dL

Random: 219 mg/dL

Lipid Profile
Total: 230 mg/dL
LDL: 145 mg/dL
HDL: 45 mg/dL
Triglycerides: 200 mg/dL

Kidney Profile
Creatinine: 1.0 mg/dL


Liver Function
ALT: normal
AST: normal

Blood Pressure
Normal: 130/82 mmHg

Cardiovascular condition

Eye Exam

Foot Exam
Normal pulses and sensation


Compliance with meal plan?
No meal plan at this time.

Compliance with exercise plan?
Limited activity and rare exercise.

Current Medications

For blood glucose:


For other conditions:

Antihistamines for nasal allergies

Nonsteroidal Anti-inflammatory Drugs (NSAIDs) for joint pain

What issues do you want to address?
a) Hyperglycemia
b) Hyperlipidemia
c) Obesity
d) Kidney disease
e) Coronary heart disease (CHD)
f) a, b and c above
g) All of the above


f) a, b and c above

I think this is the best option


Preferred Answer: (f): hyperglycemia, hyperlipidemia and obesity

Recommendations for this patient may include:

1. Lifestyle changes

Healthier diet. Schedule a consultation with a nutritionist for a weight reduction meal plan that is consistent with American Heart Association and American Diabetes Assocation guidelines.

Increased exercise. Ask patient to do some vigorous, non-weight-bearing exercise such as swimming, an elliptical machine or water aerobics for at least 20 minutes, three to four times per week.

2. Diabetes education

Patient will spend several hours with a Diabetes Educator to learn the basics of diabetes care, how to use a blood glucose meter, how to read and understand the blood glucose averaging function in the meter.

3. Blood glucose medication

With an A1c of 8.2%, which equates to a mean blood glucose of 215 mg/dL, it is unlikely that diet alone can normalize her hyperglycemia.

The patient’s blood glucose target is set at fasting blood glucose <100 mg/dL, or an overall average blood glucose of 130 mg/dL. The patient can use either metric to monitor her progress.

Initial glycemic therapy

Which medication would you choose to lower her blood glucose?

a) Metformin
b) Sulfonylurea
c) Meglitinide
d) Sitagliptin DPP4 inhibitor
e) Thiazolidinediones (TZDs)
f) Exenatide
g) Pramlintide


a) Metformin

I think this is the best


Preferred Answer: Metformin, low dose: 250 mg bid

Patient receives written instructions that in 2 weeks, if her average blood glucose is above 130 mg/dL, she should increase the metformin dose to 500 mg bid. Two weeks after that, if her average blood glucose is still over 130 mg/dL, she can titrate again to 850 mg bid. The patient can go up to a maximum effective dose of 1000 mg bid.

Twice daily dosing from the start sets up twice a day medication behavior in the patient. This tactic may improve medication compliance, since most patients with diabetes are likely to be titrated to twice daily dosing. Twice daily dosing may also help to reduce the GI side effects that some patients experience with metformin.

Metformin is the oral agent of choice for initiating therapy, per the EASD and ADA consensus algorithm.

Proven drug: expected A1c decrease = 1.5 percentage points

Dose adjustments can be made by phone or self-management every 1-2 weeks.

No hypoglycemia

Helps weight loss

Mild side effects, primarily gastro-intestinal

High success rate. Time to reach goal: 3 months.

The other drugs are not preferred at this stage of therapy because:

Sulfonylureas can cause hypoglycemia, weight gain.

Meglitinides can cause hypoglycemia, weight gain

DPP4 inhibitors are newcomers, and are costly

TZDs can cause edema, weight gain, and are expensive

Exenatide is not approved as first line monotherapy; expensive

Pramlintide (Symlin®) is not approved as first line monotherapy; expensive


Initial Treatment Plan

Blood Glucose Management

Start patient on low-dose metformin, 250 mg bid at breakfast and dinner.

Either fasting blood glucose (FBG) or mean blood glucose (MBG) can be used as a treatment target. They are slightly different. The fasting blood glucose target is <100 mg/dL. The mean blood glucose target is <130 mg/dL.

In this case, since we are initiating treatment, fasting blood glucose will be the primary guide for metformin dosing. The goal is to lower fasting blood glucose to less than 100 mg/dL.

After 1-2 weeks, if her fasting blood glucose is over 120 mg/dL, increase the metformin dose to 500 mg, bid.

Continue titrating dose up to maximum of 1 gram bid.

The goal is to lower A1c to less than 7% and as close to 6% as possible, per ADA guidelines. Note: AACE recommends a target A1c level of 6.5% or less.

It should be seen within 3 months if metformin monotherapy succeeds in reaching the A1c goal. If goal is not achieved in 3 months, add another therapy promptly.

Teach the patient to self-monitor her blood glucose. Have her check the fasting BG in the morning, before dinner, and before bedtime. Ask her to call in the numbers once a week.

Once fasting BG has dropped to 100 mg/dL or less, she can test her fasting blood glucose less frequently… around once or twice a week.


Set LDL goal at <100 mg/dL

If 3 months from now, the fasting LDL level is still over 100 mg/dL, initiation of treatment with statins is appropriate.

When do you want to see this patient again?
a) 2 weeks
b) 3 months
c) 6 months
d) One year


b) 3 months

I think this is the best option


Preferred answer: Three months

Metformin titration can be handled by phone based on the patient’s reported fasting blood glucose averages.

It should be seen within 3 months if metformin monotherapy succeeds in reaching the A1c goal.

If the goal is not achieved in 3 months, add another glycemic therapy promptly. ‘Treat to Target’ principles are to treat type 2 diabetes early, and treat aggressively, scheduling the follow-up patient visits based on the “time to succeed” of each medication’s maximum effective dose.


Thats a good discussion!