Polydipsia, Polyuria, and Elevated A1C--What's Your Next Step for This Patient?


The patient is a 53-year-old African American with type 2 diabetes, in the clinic for regular follow-up. Review the rest of his exam results and select your option for the next step(s).

A 53-year-old African-American man with a history of type 2 diabetes mellitus (T2DM), hypertension, and osteoarthritis is in clinic for follow-up of T2DM. His only complaint at this time is polyuria. Current medications include metformin, 1000 mg twice daily; lisinopril, 20 mg/d; amlodipine 10mg/d; aspirin, 81 mg/d; simvastatin, 20 mg/d; and acetaminophen 1000 mg TID. He is “mostly” adherent to the regimen but says it is still difficult for him to take multiple medications multiple times a day.

Results of his physical examination today and recent laboratory findings are WNL, with the exception of an A1C of 9.2%, up from 8.1% measured 3 months ago. Vitals are: weight, 82 kg (previously 85 kg); blood pressure, 138/88 mm Hg (previously 141/86 mm Hg); and heart rate, 74 beats/min. He does not bring a home blood glucose log to clinic. He is a manager at a retail store, works an erratic daytime schedule, and often skips breakfast or lunch. He also has a hard time following his diabetic diet. He states that he is often very thirsty, but is proud that he has stopped drinking sodas and is drinking lots of water. He also tells you that he is grateful that while his insurance provider was recently changed, you are still in his network.

Which of the following would be the best choice for this patient at this time?

A. Initiate glimepiride 2 mg daily, titrated to maximum dose of 8 mg daily
B. Initiate insulin therapy
C. Initiate liraglutide 0.6 mg daily, titrated to a maximum dose of 1.8 mg daily
D. Increase metformin to 850 mg three times daily and add saxagliptin 5 mg daily
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