Management of Type 2 Diabetes

Management of Type 2 Diabetes
A 55-year-old woman with type 2 diabetes, obesity, and hypertension has been under your care for the past 2 years. She has no history of microalbuminuria, retinopathy, or neuropathy. She has never had a cardiovascular event and reports no cardiac symptoms.

In the past, she has successfully lost weight (from 5 to 12 kg) on various diets but each time has regained all of the weight she lost. She tries to walk 30 minutes each day. She monitors her fasting glucose levels three times weekly using a personal glucometer, and her morning fasting glucose levels have ranged between 110 and 140 mg per deciliter (6.1 and 7.8 mmol liter). She has been receiving metformin (1000 mg twice a day) and glipizide (10 mg twice daily).

She has hypertension that is treated with hydrochlorothiazide (25 mg daily) and lisinopril (20 mg daily). She takes aspirin (81 mg daily) and simvastatin (20 mg daily). She notes that she consistently takes her medications.

She has a family history of cardiovascular disease with early stroke. On physical examination, her body-mass index (the weight in kilograms divided by the square of the height in meters) is 31. Her blood pressure is 128/78 mm Hg. Her general assessment, including cardiorespiratory, abdominal, and neurologic examinations, is normal.

Her glycated hemoglobin level is 8.1%, and her creatinine 0.9 mg per deciliter (80 mmol per liter). She has no microalbuminuria, and liver-function studies are normal. She seeks advice about the management of her diabetes.

Treatment Options

What kind of treatment would you find most appropriate for this patient? Three options are outlined and each is defended in a short essay by an expert in the management of type 2 diabetes; read the essays and then cast your vote.

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New England Journal of Medicine
January 17, 2008