Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 52-year-old woman with type 2 diabetes mellitus

mksap
Conditions
June 25, 2016
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 52-year-old woman presents for follow-up evaluation after being diagnosed with type 2 diabetes mellitus 6 weeks ago. Her initial HbA1c level was 8.0%. Management at this time is with lifestyle modifications. She has worked closely with a diabetes educator and a nutritionist since her diagnosis. She has lost 3.2 kg (7 lb) by making changes to her diet and activity level. Review of her blood glucose log for the past 2 weeks shows preprandial blood glucose values in the 150 to 160 mg/dL (8.3-8.9 mmol/L) range and several 2-hour postprandial blood glucose values of 190 to 200 mg/dL (10.5-11.1 mmol/L). Her only other medical problem is hypertension for which she takes lisinopril.

On physical examination, blood pressure is 125/70 mm Hg and pulse rate is 74/min. BMI is 28. There is no evidence of diabetic retinopathy. She has normal monofilament and vibratory sensation in her extremities.

Except for her blood glucose parameters, basic laboratory studies obtained at the time of her initial diagnosis were normal.

In addition to continuing lifestyle modifications, which of the following is the most appropriate management for this patient’s diabetes?

A. Initiate dapagliflozin
B. Initiate glipizide
C. Initiate metformin
D. Initiate sitagliptin

MKSAP Answer and Critique

The correct answer is C. Initiate metformin.

The most appropriate management for this patient is to initiate metformin. The patient is early in her diabetes disease course without evidence of microvascular disease. For otherwise healthy adults meeting these criteria, the American Diabetes Association recommends a HbA1c level of less than 7.0%, preprandial glucose values of 70 to 130 mg/dL (3.9-7.2 mmol/L), and 1- to 2-hour postprandial glucose values of less than 180 mg/dL (10 mmol/L). Because the patient has not met these goals, a pharmacologic agent should be added at this time. Lifestyle recommendations consisting of increased physical activity, dietary modifications, and weight loss (if BMI is elevated) are the initial first step in treating diabetes. When lifestyle modifications fail to meet glycemic goals within 6 weeks, metformin is the recommended first-line therapy to be started in conjunction with continued lifestyle modifications. If glycemic goals are not met after 3 months of lifestyle modifications and metformin use, additional agents should be added to the regimen every 3 months until glucose goals are met.

Dapagliflozin, a sodium-glucose transporter-2 (SGLT-2) inhibitor, increases excretion of glucose through the kidney. It is a second-line agent that should be used after lifestyle modifications and metformin fail to reach glycemic goals.

The sulfonylurea glipizide stimulates insulin secretion from the pancreatic beta cells. This agent could improve the patient’s postprandial hyperglycemia, but it may also induce weight gain in a patient actively working on weight loss. Glipizide is a second-line agent that should be used after lifestyle modifications and metformin fail to reach glycemic goals.

Sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, improves glycemic control by slowing gastric emptying and suppressing glucagon secretion. It is also considered a second-line agent that might be considered if lifestyle modifications and metformin fail to reach glycemic goals.

Key Point

  • For most patients with type 2 diabetes mellitus, lifestyle modifications and metformin therapy are the most appropriate initial treatments.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

A false positive is precaution by another name

June 24, 2016 Kevin 5
…
Next

Does publicly reporting hospital mortality rates improve outcomes?

June 25, 2016 Kevin 0
…

ADVERTISEMENT

Tagged as: Diabetes, Endocrinology

Post navigation

< Previous Post
A false positive is precaution by another name
Next Post >
Does publicly reporting hospital mortality rates improve outcomes?

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

Related Posts

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 45-year-old woman with type 2 diabetes mellitus

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 35-year-old woman with constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 60-year-old woman with persistent constipation

    mksap
  • Type 1 diabetes is no fun

    Ryan Ritchie
  • 3 ways we’ve failed woman who breastfeed

    Joanna Buscemi, PhD
  • How one woman prevented a pharmaceutical disaster

    James Essinger and Sandra Koutzenko

More in Conditions

  • Why psychotherapy works and why psychotherapy fails

    Peggy A. Rothbaum, PhD
  • How oral health silently affects your heart, brain, and body

    Charles Reinertsen, DMD
  • How President Biden’s cognitive health shapes political and legal trust

    Muhamad Aly Rifai, MD
  • The emotional first responders of aesthetic medicine

    Sarah White, APRN
  • Why testosterone matters more than you think in women’s health

    Andrea Caamano, MD
  • How veteran health care is being transformed by tech and teamwork

    Deborah Lafer Scher
  • Most Popular

  • Past Week

    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
  • Past 6 Months

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • How regulatory overreach is destroying innovation in U.S. health care

      Kayvan Haddadan, MD | Physician
    • Why the U.S. mental health care system is failing and how to fix it [PODCAST]

      The Podcast by KevinMD | Podcast
    • The unseen cost of detachment in radiology

      Dr. Yesu Raju | Physician
    • I thought success was a destination. Then I became a doctor.

      Ryan Nadelson, MD | Physician
    • Why psychotherapy works and why psychotherapy fails

      Peggy A. Rothbaum, PhD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
  • Past 6 Months

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • How regulatory overreach is destroying innovation in U.S. health care

      Kayvan Haddadan, MD | Physician
    • Why the U.S. mental health care system is failing and how to fix it [PODCAST]

      The Podcast by KevinMD | Podcast
    • The unseen cost of detachment in radiology

      Dr. Yesu Raju | Physician
    • I thought success was a destination. Then I became a doctor.

      Ryan Nadelson, MD | Physician
    • Why psychotherapy works and why psychotherapy fails

      Peggy A. Rothbaum, PhD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...