MKSAP quiz: Treatment escalation

This month's quiz asks readers to evaluate a woman with type 2 diabetes who has not been successful in reaching her HbA1c goal with lifestyle modifications and multiple medications.


A 62-year-old woman is evaluated for management of her type 2 diabetes mellitus. She was diagnosed 2 years ago, and treatment was advanced to include lifestyle modifications, metformin, liraglutide, and empagliflozin, but it was not successful in reaching her hemoglobin A1c goal. Her current regimen includes metformin and basal and prandial insulins. Her fasting and preprandial blood glucose values range from 150 to 200 mg/dL (8.3-11.1 mmol/L) with intermittent episodes of hypoglycemia. She has had a weight gain of 2.3 kg (5 lb) over the last 3 months. Medical history is also significant for hypertension, hyperlipidemia, and osteoarthritis. Medications are detemir insulin, lispro insulin, metformin, lisinopril, and atorvastatin.

On physical examination, blood pressure is 142/90 mm Hg and pulse rate is 63/min. BMI is 36. The remainder of the physical examination is unremarkable. Laboratory studies show a hemoglobin A1c level of 8.8%.

Which of the following is the most appropriate management of this patient's diabetes?

A. Add sitagliptin
B. Add pioglitazone
C. Increase insulin
D. Metabolic surgery referral

Reveal the Answer

MKSAP Answer and Critique

The correct answer is D. Metabolic surgery referral. This item is available to MKSAP 18 subscribers as item 83 in the Endocrinology and Metabolism section. More information about MKSAP 18 is available online.

This patient should be referred for metabolic surgery. The gastrointestinal tract plays an important role in glucose homeostasis and serves as an important physiologic target for improving glycemic control. Short- and mid-term data from randomized controlled trials of metabolic surgery demonstrated greater improvements in glycemic control and cardiovascular risk factors compared with optimized medical therapy and lifestyle modifications. Retrospective cohort studies and prospective observational studies suggest a reduction in cardiovascular deaths and lower incidence of cardiovascular events in patients undergoing metabolic surgery. Metabolic surgery should be recommended to patients with type 2 diabetes with class III obesity (BMI ≥40 [≥37.5 in Asian Americans]) independent of glycemic control and diabetes treatment regimen and to patients with type 2 diabetes with class II obesity (BMI 35.0-39.9 [32.5-37.4 in Asian Americans]) who fail to meet their glycemic goals despite optimizing medical therapies and lifestyle modifications. In addition, patients with class I obesity (BMI 30.0-34.9 [27.5-32.4 in Asian Americans]) who do not meet their glycemic goals despite optimizing medical therapy should be considered for metabolic surgery. This patient with class II obesity has an inability to meet her hemoglobin A1c goal of less than 7% on her current medical regimen. Further modifications to her current regimen may either exacerbate hypoglycemia and accelerate weight gain or not reach her glycemic goal.

Although sitagliptin, a dipeptidyl peptidase (DPP)-4-inhibitor, is a weight neutral oral agent that could potentially improve her hemoglobin A1c level by 0.95% to 1.1%, it would not achieve her target hemoglobin A1c of less than 7%.

Pioglitazone, a thiazolidinedione (TZD), improves insulin sensitivity and hemoglobin A1c by 0.9% to 1.1%. The addition of pioglitazone in this patient would likely not achieve her target hemoglobin A1c goal and could potentially induce additional weight gain, a known side effect of this drug class.

Increasing the patient's insulin doses may improve her hemoglobin A1c to goal, but it will exacerbate her hypoglycemia and promote additional weight gain.

Key Point

  • Metabolic surgery demonstrates greater improvements in glycemic control and cardiovascular risk factors compared with optimized medical therapy and lifestyle modifications.