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A 67-year-old obese (body mass index, 34) white man has had type 2 diabetes mellitus for the past 8 years. The disease was originally diagnosed on the basis of a routine fasting plasma glucose level of 156 mg/dL and responded well to initiation of a nutrition and exercise plan. The hemoglobin A1C value decreased from 8.8% at diagnosis to 6.9% after 6 months of nutrition therapy and a 5.5-kg (12-Ib) weight loss. After 2 years, the hemoglobin A1C increased to 8.1%; therapy with glyburide, titrated up to 10 mg/d, was started. The hemoglobin A1C value then decreased 6.6% and remained less than 7% until 1 year ago. At that time, the patient noted a 7 kg (15-Ib) weight gain and some symptoms of distal paresthesias. The hemoglobin A1C had increased to 7.7%. The patient is counseled to intensify diet and exercise to lose 7kg (15 Ib).
What is the most appropriate additional intervention at this time?
A. Add repaglinide therapy before breakfast and dinner
B. Increase the glyburide dosage to 10 mg twice daily
C. Discontinue glyburide therapy and begin metformin therapy
D. Add metformin therapy to the current glyburide regimen
E. Switch from glyburide therapy to glipizide therapy
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hi vanco i like your idea
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The goals of therapy for type 2 diabetes include an ideal hemoglobin A1C level less than 6.5% to 7%. A change in the therapeutic regimen is therefore indicated. The United Kingdom Prospective Diabetes Study demonstrated the progressive nature of type 2 diabetes and secondary failure of both medical nutrition therapy and monotherapy with sulfonylureas. Furthermore, sulfonylurea therapy is frequently associated with weight gain, which worsens insulin resistance. Finally, the maximal effective dosing of sulfonylureas is less than the maximally approved dose. Glycemic control rarely improves with sulfonylurea dosing beyond approximately 50% of the approved maximum amount. Multiple studies have demonstrated the advantage of adding synergistic therapies rather than substituting therapies. The addition of metformin to sulfonylurea is considerably more advantageous than replacing the sulfonylurea in the case of secondary sulfonylurea failure. The pathophysiology of type 2 diabetes suggests a benefit to the combination of an insulin secretagogue, such as glyburide, with an insulin sensitizer, such as metformin. Although the addition of pioglitazone, another insulin sensitizer, has been shown to be effective in decreasing the hemoglobin A1C level, it is associated with further weight gain. Addition of metformin to therapy with an insulin secretagogue appears to be more weight neutral and would thus have relative advantage in a patient with progressive weight gain.
yupp its d
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Addition of metformin to therapy with an insulin secretagogue appears to be more weight neutral and would thus have relative advantage in a patient with progressive weight gain.
A very importnt thing.
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u know i am little worried that despite heavy BMI, why that physcian has not started him on metformin on day first. what was the reason. his kidneys are fine.
he want to go in court. i think.
