Endocrine · Year 2 · from Endocrine

Case 1: Type 2 Diabetes - Initiating and Intensifying Therapy

Patient Demographics

  • Age: 54 years
  • Sex: Male
  • Occupation: Office manager

Chief Complaint

"My blood sugars are still high despite taking my diabetes pill."

History of Present Illness

A 54-year-old man with type 2 diabetes diagnosed 3 years ago presents for diabetes management. He was initially started on metformin 500 mg twice daily, which was increased to 1000 mg twice daily 1 year ago. Despite adherence to medication and attempts at lifestyle modification, his HbA1c has progressively risen from 7.2% at diagnosis to 8.8% at his last visit 3 months ago. He reports polyuria and polydipsia, fatigue, and recent weight gain of 8 pounds. He also has hypertension (on lisinopril), hyperlipidemia (on atorvastatin), and obesity (BMI 34). He had a myocardial infarction 2 years ago with stent placement. His father died of a heart attack at 58, and his mother has diabetes and chronic kidney disease.

Physical Examination

  • Vital Signs: BP 138/86 mmHg, HR 76 bpm, Weight 238 lbs, BMI 34
  • General: Obese, well-appearing
  • Cardiovascular: Regular rhythm, no murmurs
  • Abdomen: Obese, no organomegaly
  • Extremities: No edema, intact sensation to monofilament
  • Skin: Acanthosis nigricans at neck

Workup

  • Laboratory Studies:
  • HbA1c: 9.2% (above goal despite current therapy)
  • Fasting glucose: 218 mg/dL
  • Creatinine: 1.2 mg/dL, eGFR: 72 mL/min/1.73m²
  • UACR (urine albumin-to-creatinine ratio): 85 mg/g (moderately increased)
  • LDL: 78 mg/dL (on statin)
  • Triglycerides: 185 mg/dL
  • Recent Studies:
  • Echocardiogram: EF 50%, no wall motion abnormalities
  • Dilated eye exam: Mild non-proliferative diabetic retinopathy

Assessment

  • Type 2 diabetes, suboptimally controlled (HbA1c 9.2%, goal <7%)
  • Established atherosclerotic cardiovascular disease (prior MI)
  • Early diabetic nephropathy (moderately increased albuminuria)
  • Mild non-proliferative diabetic retinopathy
  • Obesity

Treatment Plan

AGENT SELECTION BASED ON COMORBIDITIES:

Given this patient's profile:

  • Established ASCVD → GLP-1 RA with proven CV benefit (semaglutide, liraglutide, dulaglutide)
  • CKD/Albuminuria → SGLT2 inhibitor with proven renal benefit (empagliflozin, dapagliflozin)
  • Obesity → Both GLP-1 RA and SGLT2i promote weight loss
  • Need to avoid hypoglycemia → GLP-1 RA and SGLT2i have low hypoglycemia risk

RECOMMENDED REGIMEN:

  1. Continue metformin 1000 mg BID (foundation therapy)
  2. Add GLP-1 receptor agonist (first-line add-on given ASCVD):
  • Semaglutide 0.25 mg weekly x 4 weeks, then 0.5 mg weekly, titrate to 1 mg weekly
  • Expected HbA1c reduction: 1.0-1.5%
  • Additional benefits: Weight loss (8-15 lbs), CV mortality reduction
  1. Add SGLT2 inhibitor (for CKD/albuminuria protection):
  • Empagliflozin 10 mg daily
  • Expected HbA1c reduction: 0.5-0.8%
  • Additional benefits: Reduces CKD progression, CV protection, modest weight loss

IF HbA1c REMAINS >8% AFTER 3 MONTHS:

  • Consider adding basal insulin (glargine 10 units at bedtime, titrate by 2 units every 3 days to fasting glucose goal)

COMPREHENSIVE DIABETES CARE:

  1. Glycemic target: HbA1c <7% (individualized)
  2. Blood pressure: Target <130/80 mmHg (continue ACE inhibitor for renal protection)
  3. Lipids: Continue statin, LDL goal <70 mg/dL (ASCVD)
  4. Aspirin: Continue 81 mg daily (secondary prevention)
  5. Renal protection: ACEi + SGLT2i (slow CKD progression)
  6. Eye care: Annual dilated exam (more frequent if retinopathy progresses)
  7. Foot care: Annual comprehensive foot exam, patient education

PATIENT EDUCATION:

  • GLP-1 RA: Nausea common initially (take with meals, will improve); inject weekly
  • SGLT2i: Genital hygiene (increased yeast infections); signs of euglycemic DKA
  • Lifestyle: Continued emphasis on diet and exercise

Follow-up Plan

  • HbA1c in 3 months
  • Renal function and UACR in 3 months
  • If HbA1c improved but still >7%, continue current regimen
  • If HbA1c still >8%, add basal insulin

Clinical Pearl

Current diabetes treatment guidelines emphasize a patient-centered approach that considers comorbidities rather than a stepwise escalation based solely on HbA1c. For patients with established ASCVD, GLP-1 receptor agonists with proven cardiovascular benefit (semaglutide, liraglutide, dulaglutide) are preferred regardless of HbA1c. For patients with CKD or heart failure, SGLT2 inhibitors are preferred for their organ-protective effects independent of glucose lowering. The combination of GLP-1 RA + SGLT2i is increasingly used in patients with both ASCVD and CKD, providing complementary cardiorenal protection. Weight loss with these agents also improves insulin sensitivity and may reduce the need for additional therapy.

Clinical Image

Image showing insulin delivery devices including insulin syringes and pens used for subcutaneous insulin administration in diabetes management.

Image Source: Wikimedia Commons - "Insulin syringe and pen" License: CC BY-SA 4.0 URL: https://commons.wikimedia.org/wiki/File:Insulin_syringe_and_pen.jpg

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