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A 55-year-old African American female presents to clinic as a new patient. She has not seen a physician in many years and would like a general health checkup. The patient is not treated for any chronic health problems. However, her mother had type 2 diabetes, and she would like to be screened.

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Physical examination is unremarkable except for weight of 180 lb (81.8 kg; height 165 cm, BMI 30.3 kg/m2). The patient has multiple risk factors for type 2 diabetes including age, ethnicity, and family history that justify screening. Since the patient is not fasting, hemoglobin A1c (HbA1c) is measured and found to be elevated at 6.8%. Morning fasting plasma glucose is 145 mg/dL.

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The patient returns to the office to discuss management of her newly diagnosed type 2 diabetes. She is started on metformin and titrated to 1000 mg twice daily without side effects. She also modifies her diet and starts an exercise program. Three months later, capillary blood glucose measurements are consistently below 130 mg/dL, and HbA1c improves to 6.0%. Four years later, HbA1c increases steadily to 7.5% despite compliance with diet, exercise, and metformin. Dilated fundoscopy and foot examination are unremarkable, and urine albumin/Cr ratio remains below 30 mg/g.

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Initially, HbA1c improves with the addition of glimepiride to metformin. Exenatide is then started 18 months later due to worsening glycemic control. Two years later, the patient returns to discuss treatment options. Despite taking maximal effective doses of metformin (1000 mg BID), glimepiride (8 mg QD), and exenatide (10 μg BID), HbA1c is 8.5%. Fasting glucose measurements fall mostly in the range of 140 to 180 mg/dL, and glucose measurements during the day increase steadily and are often more than 200 mg/dL.

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1. Who should be screened for type 2 diabetes mellitus?

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2. How is type 2 diabetes initially managed?

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3. What regular screening is necessary for type 2 diabetes patients?

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4. What additional therapies can be added if metformin monotherapy is ineffective?

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5. What is the next step in management for patients with progressively worsening glycemic control despite multiple oral medications or glucagon-like peptide-1 (GLP-1) analog therapy?

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Answers

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  1. All adults with BMI ≥25 kg/m2 and 1 or more risk factors summarized in Table 50-1 should be screened annually. Individuals aged 45 years or older without risk factors should be screened every 3 years.

  2. Therapeutic lifestyle change (TLC), which consists of diet and aerobic exercise, and metformin are the initial interventions for type 2 diabetes.

  3. Complete physical examination including dilated fundoscopy and foot examination with monofilament evaluation should be performed at least annually. HbA1c should be checked at 3- to 6-month intervals depending on glycemic control. Fasting lipid panels and urine albumin/Cr ratio ...

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