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 ADA recommends that all treatment regimens should be reviewed for response and tolerability every 3-6 months. If patients have not achieved a target HbA1C at that time, consideration should be given to intensifying therapy. For a patient that is already on a GLP-1 RA, the next step is to add a basal insulin analog or bedtime neutral protamine Hagedorn insulin.

A patient who requires both GLP-1 RA and basal insulin, the ADA suggests considering a fixed-dose combination of the two, allowing one instead of two injections. Two such combinations are available, one combining insulin glargine and lixisenatide and one combining insulin degludec and liraglutide. These allow titration based on the insulin dose and fasting plasma glucose.

Mealtime or prandial insulin generally is not initiated for patients with T2D unless they have uncontrolled hyperglycemia with basal insulin plus other treatments.


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