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Q: What is your initial treatment plan?
A: I recommend that she enroll in a diabetes education class. I think the decision between initiating lifestyle alone vs lifestyle plus a medication demands a shared decision-making approach. One factor in making this decision is choosing an A1c goal. If one accepts any goal under 7.0% (ADA goal),2 patience with lifestyle alone may make more sense than if one is shooting for a stricter goal of under 6.5% as recommended by the American Association of Clinical Endocrinologists (AACE).4 Obviously, her level of motivation and ability to initiate an appropriate exercise program help to make this choice. Patients can be reassured that many of the oral agent options do not preclude one’s ability to lose weight and to exercise. With patients greater than 0.5% to go to reach A1c goal, I encourage use of a medication right at the outset.
KM and I decide to initiate an exercise program with swimming and some treadmill walking. I give her some brief instruction about exercise. A physician’s ability to do meaningful dietary counseling within the time course of the 15 minute office visit is usually low. This fact accentuates the importance of using team members to help with counseling. Referral to a diabetes education program is the most common way offices deal with this dilemma, but some primary care offices have individuals with adequate expertise within their own offices. If a doctor does not refer the patient, they have the obligation to do state of the art counseling on their own.
I try to use a stage-based approach to behavior change based on the transtheoretical model.5 For precontemplative patients, patients not considering a behavior change within the next few months, I concentrate on the benefits of changing their behavior. The more benefits a patient knows, the more likely they are to change. I ask them to start thinking about
changing their behavior, (ie, changing from precontemplative to contemplative). Patients listen to their physicians and just a few minutes devoted to behavioral counseling make a difference.
In addition to lifestyle changes, drug therapy to reduce insulin resistance is an important consideration for managing this patient.
Rational pharmacotherapy is based on selecting agents that attack the underlying disease processes (see Table 4).
I selected metformin as initial therapy. For overweight patients with the metabolic syndrome, metformin is an excellent initial choice and is supported by UKPDS data.6 It is covered by almost all insurance programs.
Thiazolidinediones (rosiglitazone, pioglitazone) are also a rational choice for early diabetes. These agents are effective because they address the major metabolic defect of early type 2 diabetes—insulin resistance in muscle and adipose tissue. They also have secondary effects on glucose production in the liver and may help preserve beta cell function.7 Early in diabetes, insulin levels are usually already high or at least normal. Some insurance plans may require a letter or phone call to the insurance company to approve the use of a thiazolidinediones; they may also require initial use of metformin before giving approval.
If a patient is intolerant of metformin, first check on your dosage escalation schedule to ensure that you have not advanced therapy too rapidly. The extended release formulation may be better tolerated in some patients.
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