Usual and Not So Usual Cases in Type 2 Diabetes: What do

Usual and Not So Usual Cases in Type 2 Diabetes: What do you Recommend?

Dianne Cheung, MD MPH

Associate Clinical Professor

UCLA David Geffen School of Medicine

UCLA Health - South Bay Endocrinology

President Elect - Clinical Association of California Endocrinologists (CACE)

No financial disclosures

Approach to managing patients with Type 2 DM –One Size Does Not Fit All

Individualizing diabetes care and recognizing patient’s associated diabetic complications (CAD, CHF, CKD)

1Using the guidelines in practice while identifying potential barriers to success

2Using the new therapies while minimizing side effects

3Using diabetes technology to reach individual glycemic control goals

4

“The Ominous Octet”Multifactorial Pathophysiology of T2D

Increased lipolysis

Increased glucosereabsorption

Increasedglucagonsecretion

Increased hepaticglucose production

Neurotransmitterdysfunction

Decreasedglucose uptake

Decreasedincretin effectImpaired insulin

secretion

Hyperglycemia

DPP4iGLP-1 RAsDPP4i

GLP-1 RAsSUs Glinides

DPP4iGLP-1 RAs

MetforminTZDs

Metformin

TZDsMetformin

SGLT2iNormoglycemia

GLP-1 RAsBromocriptine

DPP4i, dipeptidyl peptidase-4 inhibitors; GLP-1 RA, glucagon-like peptide-1 receptor agonist; SLGT2i, sodium-glucose cotransporter 2 inhibitors; SU, sulfonylureas; T2D, type 2 diabetes; TZD, thiazolidinediones.

Adapted from DeFronzo RA. Diabetes 2009;58:773-795.

ADA Guidelines. Diabetes Care. 2021

AACE Guidelines 2020

Basic Principles in the ADA Guidelines • Lifestyle modification key• Metformin preferred first line (but AACE says GLP1-r agonist or SGLT2i first okay)• Once started metformin should be continued if possible unless contraindicated or intolerant• Early combination therapy if needed• May need to start insulin if urgent need

• The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10% [86 mmol/mol]) or blood glucose levels (≥300 mg/dL [16.7 mmol/L]) are very high. (ADA guidelines 2021)

• Individualize care – if CAD/CHF/CKD, cost an issue, or preference• consider SGLT2i or GLP-1 receptor agonist independent of glycemic control (if CKD, CAD, HF)• In patients with type 2 diabetes, a GLP-1 receptor agonist is preferred to insulin when possible• Intensify treatment as needed • Do not overinsulinize patients

Usual Cases of DM Type 2

How to manage in 2021

Case 1 – T2DM already on Metformin

• 66 y.o. female with prior hx of prediabetes x 8 years, hypertension, and obesity (BMI 35) who presents with HbA1c 8.2% now with overt Type 2 Diabetes Mellitus

• She has been compliant with taking metformin 1000mg twice daily, rosuvastatin 10mg daily, and losartan 50mg twice daily

• Her HbA1c 12-months before was 6.2% (prior HbA1c 5.6-5.9%) and she was started on metformin 1000mg twice daily for prevention of diabetes

• She was an avid daily walker and swimmer, but admits to “pandemic stress” and has been staying home being inactive

• Has been stress eating and has gained 12-1bs in the last 6 months


• She has only occasionally checked her sugars, AM fasting averaging 132mg/dl with a range of 120-160mg/dl

• She went to an urgent care for UTI symptoms, and random glucose check found to have glucose reading of 252 mg/dl

• In addition to ciprofloxacin for her UTI, she was prescribed RX for Glargine insulin 20 units at bedtime.

• Patient refused to start insulin and presents in endocrinology clinic referred for poorly controlled diabetes


Lifestyle modification

Case 1 – Lifestyle Modification • Patient was referred to our RD CDE, who

saw her the next day via Telemedicine visit

• Carb controlled diet and exercise plan was initiated

• CGM Professional trial (Libre Pro in this case) was placed on the day of her visit with me “blinded” she was able to keep it on for 9 days

• Patient was also told to record AM and 2-hour post meal sugars on her own Food and activity log was kept

• She started brisk walking 30-45 minutes a day and counting carbs and calories

• She got out the FitBit she had in the drawer and started tracking her steps


• Her HbA1c after 3-month lifestyle modification now at 7.2%• Despite glycemic control she has not been able to lose much weight • BMI remains above 30• What do we do next?



• GLP-1 receptor agonist semaglutide was initiated at 0.25mg SQ weekly, and intensified after 4 weeks to 0.50mg SQ weekly

• She had minimal side effect other than some nausea and diarrhea with the first few doses

• After 3-months her HbA1c now is 6.8% and she has lost approximately 8-lbs• Patient denies hypoglycemia • She is back for follow up and the plan is to further intensify treatment to the

next dose to meet her BMI goal <25 by increasing to next dose of semaglutide if tolerated 1mg SQ weekly

• What if she does not tolerate increase? What do we add next if she has not met weight goal and/or HbA1c goal?



• Can add SGLT2-inhibitor• In this case I added what was covered by the insurance, empaglitfozin 10mg

daily, but any SGLT2-i would be fine• Remember patient had UTI before, so discuss risk of UTI, yeast infection,

volume depletion • Reduce if needed her ARB dose given BP may decline • I had her come back 4-6 weeks later to assess glycemic control, volume

status, and monitor side effects • I usually order a BMP +/- UA • Please inform patient and any other provider who may be seeing your

patient that the +3 or +4 glucose found in UA is NORMAL on SGLT2i

Case 2 – Longstanding T2DM metformin intolerant –trying something new

• 62 yo male with T2DM x 15 years, hyperlipidemia presented initially to endocrine clinic with HbA1c of 8.4%

• currently on no diabetes medication therapy • He has no history of CAD, CHF, CKD • He is an avid runner runs 5 miles per day, has BMI 23, both his parents

developed insulin-dependent diabetes in their 60s. • Though he admits occasionally “indulging on sweets and wine”, he reports

a very high protein low carbohydrate diet and eats 1500 calories a day.• His fingerstick fasting sugars have ranged in the 110-130mg/dl range and

2-hour post meal has been between 140-280mg/dl

Case 2 – Longstanding T2DM metformin intolerant –trying something new

• Trial of metformin a few years before lead to severe GI upset, diarrhea. Also he felt it caused severe erectile dysfunction – so was discontinued

• He was on pioglitazone (Actos) 30mg daily but gained weight, and his blood sugars did not improve so he stopped taking it.

• He is on rosuvastatin 20mg daily and lisinopril 10mg daily• A SGLT2 inhibitor is prescribed, and he is started on empagliflozin

(Jardiance) 10mg daily• His fasting and post meal sugars improved and after two months he was

increased to 25mg daily (HbA1c came down to 7.2%)

Case 2• He then 3 months later he had an episode of flu-like symptoms, which

led to dehydration, decreased appetite.• However, the patient continued to take his medications including his

empagliflozin • He also indulged in a “few glasses” of wine nightly for two weeks to

“calm his stomach” and drank 2-3 cups of coffee during the day to stay awake

• Patient was admitted to the hospital found to have euglycemic DKA* • *usually meaning plasma glucose <250 mg/dL with DKA

Demonstration of the cascade of clinical events and metabolic changes that contribute sequentially to progressive clinical deterioration and development of full-blown episodes of

euDKA.

Julio Rosenstock, and Ele FerranniniDiabetes Care 2015;38:1638-1642 (both images)

euDKA hypothesis of SGLT2i use – dehydration and insulinopenia

Perry RJ and Shulman GI, JBC (2020)295(42)

Consider predisposing

factors for Euglycemic

Diabetic Ketoacidosis in

Type 2 DM

• Do not be afraid to use SGLT2-inhibitors• For many patients, the benefits outweigh risk• Counsel patients and educate prior to starting• Monitor chemistries and symptoms

Julio Rosenstock, and Ele FerranniniDiabetes Care 2015;38:1638-1642 (both images)

Predisposing factors for euDKA on SGLT2 inhibitors

Illness

Recent surgery

Reduced food intake

Reduced fluid intake

Reduced insulin doses (if on insulin)

Longstanding type 2 diabetics who are insulinopenic

Possible undiagnosed latent onset type 1 Diabetics

Alcohol consumption

Case 2 – Euglycemic DKA

• He presents to endocrine clinic, 4 weeks after his hospitalization• Discharged on glargine 20 units at bedtime and Humalog 8 units three times daily before

meals • Despite anion gap closed, his glucose readings remained high

• AM fasting 130-150mg/dl • 2-hour post meal sugars despite not eating much 150-220mg/dl• HbA1c 9.2%

• Antibodies for type 1 DM were negative• Random glucose reading 190 mg/dl in clinic with a cpeptide of 0.9 • Still with some blurred vision, polyuria, and malaise • What do we do next?

AACE Guidelines 2020

Case 2

• Initiated Basal and prandial insulin given low insulin secretion • Met with CDE and RD

Insulin Regimen as follows • Long-acting insulin dose: glargine (Lantus) 10 units in the morning and 10 units in the evening • Prandial insulin lispro (Humalog) before meals (he chose to carb count, variable with carbohydrate

intake per meal and wanted flexibility that a sliding scale does not have)• 1. 1 unit per every 8 grams of carbs • 2. Correction of premeal sugar give extra 1 unit per every 30 mg/dl above 100mg/dl target sugar • 3. Add step 2 and 3 together = total insulin Humalog before meal

• Patient started on a CGM – DEXCOM G6 personal • After approximately 6 months – his HBA1c 5.9%• He has stopped drinking alcohol, eats a more balanced carb-controlled diet, with daily exercise

Case 2

Case 2 – Type 2 DM controlled on insulin only

• What do we do next?• A. Nothing, he’s perfectly controlled• B. Rechallenge him with metformin • C. consider GLP-1 receptor agonist • D. Start him on a sulfonylurea and discontinue prandial insulin to minimize

insulin use

What does the guidelines say?


Case 2 – Type 2 DM controlled on insulin only

• What do we do next?(C). consider GLP-1 receptor agonistConsiderations when adding GLP-1 receptor agonist for this patient• Lowering both basal and prandial insulin due to “tight control” as

demonstrated by both the HbA1c and the Time in Range (100%)• Close monitoring to continue to reduce insulin dose over time• Cost – if the cost it prohibitive, then staying on insulin may be the most cost-

effective and safest for this patient • Could we restart him on SGLT2-inhibitor now that he has been on insulin? We

could but with caution, but I decided against it in his case due to past lifestyle habits

Case 3 – Out of control Type 2 DM

• 52 y.o. Type 2 DM x 5 years, poorly controlled 13.9% at presentation to endocrine clinic referred by his primary care doctor

• His point of care glucose was 410 mg/dl at the visit, said he just ate lunch• Currently taking metformin 750mg 1 pill daily, says he cannot tolerate more causes severe

diarrhea • Had been resistant to adding new DM meds offered by PCP • Now experiencing – polyuria, weight loss (20-lbs in the last year), excessive thirst, pain in his

feet, and blurred vision. • Eats large amounts of carbs per day particular bagels and potatoes, eats 6-7 oranges a day,

doesn’t eat much protein, likes to drink soda, eats on the road while working mostly fast food. • Does not exercise• Is on atorvastatin 20mg daily and lisinopril 5mg daily

Case 3 – Out of control Type 2 DM

Due to symptoms, we started Basal/Prandial insulin

• Blurred vision• Polyuria• Polydipsia• Unexplained weight loss • Pain in his feet

Case 3 – out of control diabetes

• Continue metformin ER 750mg 1 pill daily • Long acting insulin dose:

• Tresiba (degludec) 30 units daily • Meal time insulin dose:

• Humalog (lispro) before breakfast, lunch, and dinner sliding scale 8-12 units before each meal

• Advised to check sugars before each meal and bedtime

• Referred to Diabetes Educator and Dietician

• Encourage lifestyle modification with carb-controlled diet and adding protein to his meals

• Scheduled a return to clinic in 4-6 weeks

Average glucose 127 mg/dl (2weeks)range 79-264 mg/dl checking 2-3 times per day

Case 3 • At his 6 week visit he reports

episodes of feeling hypoglycemia, had to eat more to avoid lows

• Tresiba and Humalog doses reduced (Tresiba 20 units daily and Humalog 6-10 units qac tidSS)

• CGM professional trial • He liked it so much he got his

own

Case 3• Patient returned to clinic had self

reduced his Humalog to 4-5 units per meal due to hypoglycemic excursions he noted on the CGM

----------------------------------------------• GLP-1 receptor agonist was

added, Humalog was d/c • Ozempic (semaglutide) 0.25mg

weekly x 4 weeks, the 0.5mg weekly thereafter

• Tresiba was reduced as well to 16 units a day from 20.

• Instructed to reduce further to 8 units daily if he experiences hypoglycemia

Case 3 – off prandial insulin

• Time in Range now 98%

• Tresiba 8 units daily • Off Humalog• Ozempic 0.5mg

weekly tolerated well • metformin ER 750mg

once daily

Case 3 – “falling off the wagon”• On most recent visit 2 months

later • Went on vacation forgot to

bring his Ozempic• Was off for 4 weeks

• Continued Tresiba 8 units daily and metformin 750mg daily

• Also forgot to bring extra CGM sensors so was off sensor a week

• Felt “out of control” without sensor and GLP-1 receptor agonist

• Ate more, didn’t exercise

Time in Range

HbA1c versus using CGM Time in Range

• HbA1c reflects average glucose 3-months

• But lacks information about acute glycemic excursion (hypo-and hyperglycemia)

• Does not identify the magnitude and frequency of the excursions on a daily basis

• Certain conditions can confound measures

• Racial disparities in HbA1c makes one size fit all cut-offs inaccurate

https://www.niddk.nih.gov/health-information/diagnostic-tests/a1c-test?dkrd=/health-information/diabetes/overview/tests-diagnosis/a1c-test#diagnose

Measure of HBa1c depends on Red Cell Survival

Falsely high values cell turnover is low more older red cells.

Falsely Low values rapid red cell turnover more younger red cells.

J Fam Pract. 2014 April;63(4):198-205

Tadej Battelino et al. Dia Care 2019;42:1593-1603

CGM-based targets for different diabetes populations.

Case 4 - T2DM new patient reason for visit “I just need refills”

• 73 yo male with Type 2 DM, obesity (BMI 36), CKD stage 3 (eGFR 50) with persistent microalbuinuriapresents to establish care, needs refills on his medications which he had been on for at least 7 years

• Current regimen • Pioglitazone 30 mg daily • Metformin 500mg twice daily• Glipizide 10mg twice daily • Glargine 30 units at bedtime • Atorvastatin 40mg at bedtime• Losartan 50mg daily • HCTZ 12.5mg daily

• HbA1c 7.2% • Does not check his sugars but says “My HbA1c is always the same, I just want my refills my doctor

retired”

What do we do next?

Case 4 “I just need refills”

• Upon further questioning and exam • persistent lower extremity edema pitting to 2+ mid calf bilaterally

• Microalbumin/Creatinine ratio • Value: 505.3High Reference range: <30.0 mcg/mg• Reports orthopnea, needs to sleep with several pillows • Frequent bouts of hunger during the day and lightheadness• Relieved with eating • He reports he had seen a cardiologist a few years before and had done an

echocardiogram, but he does not recall what the results were but at one point was given furosemide

• What may he have?Congestive Heart Failure

CHF risk with traditional DM therapies

Case 4 - “I just need refills”

• Prior Echocardiogram two years prior found EF to be 35-40%

• He had a repeat Echo ordered with same result

• Take out the TZD and SU• So we add SGLT2-inhibitor

• Pioglitazone 30 mg daily • Metformin 500mg twice daily• Glipizide 10mg twice daily • Glargine 30 units at bedtime • Atorvastatin 40mg at bedtime• Losartan 50mg daily • HCTZ 12.5mg daily • Add Farxiga (dapagliflozin) 10mg daily


Case 4 – plan for possible adverse events –clinical pearls • Consider side effects to SGLT2i

• Dehydration – consider reducing or discontinuing diuretics, patient educate about hydration (i.e. 8-10 glasses of water a day though with heart failure patient probably not as much)

• Hypoglycemia on insulin - may need to lower basal/prandial insulin to reduce risk of hypoglycemia by 10-20%, recommend close monitoring

• Monitor eGFR – not helpful for glycemic control if falls below <45 – contraindicated if <30

• Look for hyperkalemia – if on potassium supplements, reduce dose or d/c

• Monitor for UTIs and mycotic infection

• ketoacidosis risk – patients who stop eating, not eating, eating only protein, become ill and continue to take SGLT2i and not hydrating

• I tell a patient if they are so sick they can’t eat or drink, stop SGLT2i until eating and drinking again

Case 4 follow up • 3 months after starting Farxiga (dapagliflozin) 10mg daily• HbA1c 6.8% • Denied hypoglycemia • Down 14-lbs in the last 3 months • Reduction of Lantus (glargine) dose to 20 units daily • Lower extremity edema improved• Orthopnea resolved • Patient experienced lightheadedness and rising Cr, which both resolved once HCTZ was

discontinued • Before SGLT2i

• MACR Value: 505.3High Reference range: <30.0 mcg/mg• After SGLT2i

• MACR Value: 300.2 High Reference range: <30.0 mcg/mg

Case 5 – Not meeting HbA1c goal

68 y.o. female with T2DM, BMI 32, presents with concerns of not reaching her HbA1c goal, weight gain and hypoglycemia symptoms.

HbA1c 7.7% which is down from 8.5% after the start of basal insulin glargine by prior endocrinologist

Current DM regimen• Glargine 55 units SQ at bedtime – started at 20 units and told by prior MD to increase dose every 2

days by 5 units until AM sugar <100mg/dl (recently added when HbA1c was 8.2% with agents below)

• Invokana 300 mg• Metformin 500mg 2 pills in the AM and 2 pills in the PM• Trulicity (dulaglutide) 1.5 weekly.• Glipizide 5mg twice daily.

Only checks AM fasting glucose and gets a range of 65-90mg/dl Wants to know despite low AM fasting why does she not reach HbA1c goal <7%

Case 5 – overinsulinized

Case 5 – Not meeting HbA1c goal

During the day she feels very hungry and eats cooked apples in a soup was told that apples are okay to eat for diabetes

Changes to regimen I did for this patient • Lowered and also changed insulin to glargine 25 units at bedtime • Continue Invokana 300 mg daily • Continue metformin 500mg 2 in the AM and 2 in the PM• Increase Trulicity to 3.0mg weekly • Discontinue glipizide

• In subsequent visit I changed her glargine to degludec (Tresiba) 20 units daily to minimize hypoglycemia (degludec and glargine U300 less risk of hypoglycemia compared to glargine U100)

• She has since met with the dietician and is now down 8-lbs in the last 3 months • HbA1c now 7.1 % but no longer having hypoglycemia


Not So Usual Cases of DM type 2

But you may see them in your practice

Case 6 - Lean Type 2 diabetic?

• 77 y.o. female with PMH of T2DM, osteoporosis, and dementia presents to endocrine clinic with worsening HbA1c that began in 2016 despite being on metformin. Dx’d with T2DM in 2012.

• BMI 16.5• She has been “thin all her life” but had in recent years lost weight (about 10-lbs) saw her PMD and HbA1c was

measured at 7.3% and diagnosed with T2DM

• Was started on metformin ER 500mg twice daily

• Tried to maintain carbohydrate control diet and exercise • Dropped 5-lbs and HbA1c improves to 6.6%

• On a trip to her homeland, she ate more than usual, gained 7-lbs, and returned with HbA1c 7.5%

• Her PMD started increased her to metformin ER 750mg twice daily• Patient continued to lose weight another 5-lbs, but glucose readings remained high especially post-meals (2hr

post meal 140s-200s mg/dl)

Case 6 - Lean Type 2 diabetic or LADA

• Hba1c rose again to 8.0% • Glipizide 5mg daily added by PMD and she developed hypoglycemia, discontinued • Presented to Endo Clinic with Hba1c 7.3% on metformin ER 750mg twice daily alone• RX of sitagliptin started but did not lower her HbA1c so was discontinued • Given patient was cared for by caregivers during the day, family wish to avoid insulin• She was started due to concerns for hypoglycemia on CGM – family chose Libre CGM Personal• Nateglide 60mg before meals started t.i.d. – HbA1c improved to 7.0% and minimal lows (<2%)• Shortly after her husband passed away, which leads to furthering progression of her dementia• She presents to endocrine clinic at that time with Hba1c 9.1% with BMI 16 on metformin and

nateglinide

Case 6 - Lean Type 2 diabetic or LADA

• GAD-65Ab was ordered and she tested high • Reference range: 0.0 - 5.0 U/mL• Value: >250.0 High

• C-peptide tested initial was 1.7 (reference 1.1-4.3 ng/ml) glucose reading 175mg/dl• Diagnosed with Latent onset Autoimmune Diabetes of Adulthood (LADA)• Glargine basal insulin (U100) initiated at 10 units at bedtime and later changed for to Tresiba

due to hypoglycemia • She started having episodes of hypoglycemia at times with nateglinide but if she skipped dose

prior to meal she would have very high post meal glucose readings• d/c of nateglinide added lispro (Humalog) 1-4 units qac t.i.d. on sliding scale (1 unit for every

50mg/dl above 100mg/dl) and Tresiba at 10 units once daily

Case 6 – LADA – HbA1c changes

Metformin only

Metformin +nateglinide

Metformin +nateglinide and stressor

Metformin +nateglinide and glargine basal

Metformin +nateglinide and glargine basal

Metformin +nateglinide and Tresiba insulin, metformin was removed

d/c nateglinide, Metformin added back +Aspart(Humalog) tidwith meals and Tresiba insulin

nateglinide and Tresiba insulin Reports of hypoglycemia with increased hunger

On Tresiba and Humalog sliding scalewith a touch of metformin 500mg once daily

On recent visit I lowered her Tresiba dose from 10 units to 9 units as her TIR is too high for patient of her age with dementia, high risk of hypoglycemia

Latent Autoimmune Diabetes in Adults

• This is T1DM not T2DM• Often misdiagnosed and treated as T2DM• Slow progression to T1DM adult onset with autoimmune antibodies • B-cell function declines and tends to be slower than T1DM• As in our case she would have improved HbA1c at times or hypoglycemia

same regimen, no change in lifestyle • Insulin requirement can occur within 5 or 6 years of onset (our patient dx’d

in 2012 with diabetes and started insulin in 2017) • Secretagogues if used must be used with care – risk of hypoglycemia

especially elderly • Antibodies to test: GAD65 Ab, islet cell autoantibody (ICA), IA-2A, Zinc

trasporter 8 antibody ZnT8A, insulin autoantibody

T1DM vs LADA vs T2DMType 1 DM LADA T2DM

Age of Onset Young 5-10%

Adults (> 30)2-12% of all patients with adult-onset diabetes

Adults90%

Antibodies Yes Yes - titers/levels varyGAD 65Ab most sensitive

no

Genetics Type 1 Mixed features of both but mostly of Type 1

Type 2

Weight Usually Thin

Usually Thin

Usually Overweight/Obese(but there are T2DM lean patients)

Family Hx Usually not specifically LADA but autoimmunity personally or in family

Usually no Yes

Insulin dependence From the start Over time 5-6 years from onset (but no insulin use first 6 months)

Variable or none

Insulin resistance No Some Yes

Buzzetti et al. Diabetes 2020;69:2037-2047

Case 7 - Type 2 DM and Weight gain

• 46 y.o. female newly diagnosed with newly diagnosed T2DM and HTN presents to endocrine clinic for further evaluation due to 50-lb sudden weight gain over the past year.

• She came for “diet drug” or if she’s a candidate for bariatric surgery, extremely upset, depressed, fatigued• Her weight usually is 110-lbs and now she weighs 160-lbs BMI now 32

• HbA1c 7.1%

• Placed on metformin 1000mg twice daily • Patient eats 1000-1200 calorie/day diet, exercises on her treadmill and exercise bike for 1.5 hours per night

but continues to gain weight

• She succeeded in losing 20-lbs over 4 months with intense exercise and high protein and very low carb diet but despite those efforts weight came back

• Physical exam – obese female with round puffy face, thick fat pad neck, dark stretch marks, dark skin around neck, CV tachycardic

• Vitals: BP 160/72, HR 95 bpm

• What does she have?

Case 7 - Type 2 DM and Cushing’s syndrome

Case 7 - Type 2 DM and Weight gain

• Cushing’s Disease

• AM cortisol and ACTH high, high urinary cortisol

• high midnight salivary cortisol

• 1mg overnight dexamethasone suppression did not suppress

• In this case she had Adrenal Cushing’s

• CT scan found - a 2.1 cm right adrenal lesion

• Underwent right adrenalectomy at UCLA

• She did require hydrocortisone for 6-months and weaned off

• She came off metformin once hydrocortisone discontinued

• BP normalized almost immediately post-op

• HbA1c improved • 3-month post op 6.0% (on metformin 500mg bid) • 1 year after surgery came down to 5.8% (been off metformin x 6 months)• 2 year post op 5.4%

• But has since lost 40-lbs and now 120-lbs

Take home points for cases

• Individualize care • Benefit of new therapies for not just

diabetes, but cardiac and renal benefits• Staying on the same regimen a patient has

been on to keep HBa1c “at goal” may not be enough and may in fact be dangerous (hypoglycemia)

• HbA1c may not be the best indicator glycemic control, consider Time In Range with CGM data

• Knowing side effects of new therapies and counseling patients may help avoid them

• Lifestyle changes with and without metformin may be all you need

Thank you

Documents

Usual and Not So Usual Cases in Type 2 Diabetes: What do