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A glycosylated hemoglobin (A1C) level can be used to diagnose

diabetes, in addition to a fasting plasma glucose (FPG) or oral glucose

tolerance test (OGTT). Each test must be confirmed on a subsequent

day.

Case 53-2 (Question 1),

Case 53-11 (Question 1)

The primary metabolic goals for diabetes are an A1C less than 7%, a

systolic blood pressure less than 140 mm Hg, and statin therapy for

most patients over the age of 40. Management of cholesterolshould

include a statin drug, and management of hypertension should include an

angiotensin-converting enzyme inhibitor or angiotensin II receptor

blocker.

Case 53-2 (Question 2),

Case 53-11 (Question 2)

Glycemic treatment goals should be individualized. For patients with a

short duration of diabetes, long life expectancy, and no significant

vascular disease, more stringent goals can be considered, if it can be

achieved without increasing hypoglycemia. For patients with existing

vascular disease, other significant macrovascular or microvascular

disease, a history of hypoglycemia, or limited life expectancy, or for

those with long-standing diabetes who have difficulty lowering their

A1C, a less stringent A1C goalshould be considered.

Case 53-2 (Question 2),

Case 53-4 (Question 2),

Case 53-11 (Question 2),

Case 53-18 (Question 3)

Medical nutrition therapy (MNT) and physical activity are cornerstones

to the treatment of diabetes.

Case 53-2 (Questions 11,

12), Case 53-11 (Question

3),

Case 53-18 (Question 4)

Self-monitoring of blood glucose (SMBG) should be performed by all

patients with Type 1 diabetes and most patients with Type 2 diabetes,

particularly those on antidiabetic therapy that can cause hypoglycemia

or those engaged in self-management. The key to SMBG is to educate

patients on how to respond to their blood glucose (BG) levels.

Case 53-2 (Questions 9–11),

Case 53-4 (Question 5),

Case 53-11 (Question 6)

Basal-bolus insulin regimens should be used for patients with Type 1

diabetes. These can be administered either by multiple daily injections or

by an insulin pump. Basal-bolus insulin regimens are also effective for

patients with Type 2 diabetes who no longer are able to achieve A1C

goals with noninsulin therapies.

Case 53-2 (Questions 3–6),

Case 53-4 (Question 3),

Case 53-13 (Question 6)

Metformin is the first-line therapy for Type 2 diabetes unless a patient Case 53-11 (Questions 3–5)

has a contraindication to its use or is unable to tolerate this agent. It

should be added at diagnosis along with lifestyle changes.

After monotherapy, a second antidiabetic agent should be added to the

regimen. Factors to consider include the patient’s A1C goal, the amount

of reduction in A1C required, the patient’s kidney and liver function,

medication side effects, and cost of therapy.

Case 53-11 (Question 7),

Case 53-12 (Question 1),

Case 53-13 (Questions 2–4)

InType 2 diabetes, insulin therapy should be considered any time the

patient’s A1C is severely uncontrolled (e.g., A1C >10%) and also when

the A1C is more than 8.5% to 9%, and a patient is already on

combination oral therapy. It should be considered whether a patient is

symptomatic.

Case 53-11 (Question 7),

Case 53-12 (Question 1),

Case 53-13 (Question 5)

p. 1071

p. 1072