Mrs. D who is a 55 year old postmenopausal woman with a eight year history of type 2 diabetes. She weighs 54 kg and her BMI is 23. She has been struggling to achieve her glycemic target and her current A1c is 8.6. She regularly works out at her gym at least five days a week and follow her dietician advice on most days. Her last visit to a Gynecologist was about four months ago for vaginal yeast infection which cleared after a week of topical antifungal therapy. The infection has not recurred after that episode. Her current medications include metformin plus sitagliptin 100 mg per day in a combination pill. She has no other complaints and her other lab parameters are normal. She is not very keen on initiating an injectable drug at this point of time. So how can we help this patient to achieve her glycemic targets?
She is relatively lean and developed diabetes at not an old age, she developed it in her late 40’s and I would make sure this isn’t LADA. So I would measure antibodies just to see because this is somebody who’s actually fit, who’s exercising, who’s adhering and in whom oral agents aren’t working. So I would want to make sure this isn’t somebody that I need to give a basal insulin injection by measuring antibodies and watching her. If she doesn’t want injection obviously a SGLT-2 inhibitor would be helpful but you would have to set weight goals here quite carefully because she has a BMI of 23 and it might not be bad for her to loose a little weight, who doesn’t want to be thinner but you want to be careful not to have her lose too much weight and I would want to watch her carefully and just make sure you are not getting into trouble and it doesn’t act as a contraindication that she’s has a mycotoxins genital infection but I would make sure that she’s aware of what to look for and how to treat if it recurs.