Diabetes

The

n e w e ng l a n d j o u r na l

of

m e dic i n e

Cl inic a l Decisions
Interactive at www.nejm.org

Management of Type 2 Diabetes
This interactive feature addresses the diagnosis or management of a clinical case. A case vignette is followed by specific clinical
options, none of which can be considered either correct or incorrect. In short essays, experts in the field thenargue for each
of the options. In the online version of this feature, available at www.nejm.org, readers can participate in forming
community opinion by choosing one of the options and, if they like, providing their reasons.
c a s e v igne t t e

A 55-year-old woman with type 2 diabetes, obesity,
and hypertension has been under your care for
the past 2 years. She has no history ofmicroalbuminuria, retinopathy, or neuropathy. She has
never had a cardiovascular event and reports no
cardiac symptoms.
In the past, she has successfully lost weight
(from 5 to 12 kg) on various diets but each time
has regained all of the weight she lost. She tries
to walk 30 minutes each day. She monitors her
fasting glucose levels three times weekly using a
personal glucometer, and her morningfasting
glucose levels have ranged between 110 and
140 mg per deciliter (6.1 and 7.8 mmol liter). She
has been receiving metformin (1000 mg twice a
day) and glipizide (10 mg twice daily).
She has hypertension that is treated with hydrochlorothiazide (25 mg daily) and lisinopril (20 mg
daily). She takes aspirin (81 mg daily) and simvastatin (20 mg daily). She notes that she consistently takes hermedications.
She has a family history of cardiovascular disease with early stroke. On physical examination,
her body-mass index (the weight in kilograms divided by the square of the height in meters) is 31.
Her blood pressure is 128/78 mm Hg. Her general

assessment, including cardiorespiratory, abdominal, and neurologic examinations, is normal.
Her glycated hemoglobin level is 8.1%, andher creatinine 0.9 mg per deciliter (80 mmol per
liter). She has no microalbuminuria, and liverfunction studies are normal. She seeks advice
about the management of her diabetes.
Which one of the following treatment options, any one of which could be considered
correct, would you find most appropriate for this
patient? Base your choice on the published literature, your past experience, recentguidelines, and
other sources of information, as appropriate.
1. Add pioglitazone.
2. Add neutral protamine Hagedorn (NPH) insulin before bedtime.
3. Add exenatide twice daily.
To aid in your decision making, each of these
approaches to treatment is defended by an expert
in the management of diabetes in the following
short essays. Given your knowledge of the condition and the points madeby the experts, which
treatment approach would you choose? Make your
choice on our Web site (www.nejm.org).

t r e atment o p t i on 1

Add Pioglitazone
Ronald B. Goldberg, M.D.
The case vignette illustrates a key therapeutic
decision most physicians face when managing
t ype 2 diabetes: namely, how to advance treatment in patients whose glycated hemoglobin levels remain above the targetvalue despite dual oral
antihyperglycemic therapy, such as with metfor-

n engl j med 358;3

min and glipizide, as in this patient. Medications
such as pioglitazone can delay the almost inevitable necessity of initiating the use of insulin in
such patients. Furthermore, patients receiving a
thiazolidinedione who later need insulin may
have a better response to it than those not receivinga thiazolidinedione. However, there are no
comparative data to determine what the optimal
treatment should be when a patient does not have

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a response to dual oral therapy. I believe the...