Skill Checkup: A 55-Year-Old Man With Type 2 Diabetes and High A1C Level Despite Previous Treatments

Romesh Khardori, MD, PhD


April 27, 2023

The Skill Checkup series provides a quick, case-style interactive quiz, highlighting key guideline- and evidence-based information to inform clinical practice.

The patient is a 55-year-old man in the United States diagnosed with type 2 diabetes (T2D) 4 years ago. At diagnosis, his hemoglobin A1C (HbA1C) = 9.0%. He began treatment with metformin 800 mg/day and achieved HbA1C of 8.1% after 3 months. After 6 months on that dosage, his HbA1C was still 8.0%, and his regimen was changed to 500 mg metformin twice daily plus an oral dipeptidyl peptidase-4 (DPP-4) inhibitor. His HbA1C decreased to 7.7% and stabilized, and he stayed on that regimen for 3 years. Six months ago, his HbA1C had increased to 7.9%, and a third oral agent was added. He now takes metformin 500 mg twice daily, a DPP-4 inhibitor once daily, and a sodium-glucose cotransporter-2 (SGLT2) inhibitor once daily. Along with medication, he has made efforts to adopt a healthier diet and increase his physical activity but admits he is inconsistent in following the recommendations. He presents today with renewed concerns about his diabetes management, reporting that a coworker with T2D recently had a heart attack. He admits to missing a dose of one or more of the medications several times a week owing to scheduling and asks what options he has to better control his hyperglycemia. At this visit, his body mass index is 26.5 kg/m2, blood pressure is 122/80 mm Hg, and lipids and renal function are within normal limits. His HbA1C = 7.4%.


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