Mr. X is a 31-year-old male who has been diagnosed with type 1 diabetes since the age of 14. He has a history of pancreatitis in 2008. He came to the clinic a year ago at age 30 with A1C = 9.1%, weight = 290.40 lbs and body mass index (BMI) = 36.79 kg/m2. He was on an insulin pump with 138 units basal and 22 units pre-prandial dose. He was started on metformin 1000 mg twice a day and dapaglifozin 10 mg daily. His insulin was switched to U-500 25 units twice a day which was increased to 50 units twice a day due to his high insulin resistance. He was also started on atorvastatin 20 mg daily, fenofibrate 54 mg daily and pioglitazone 15 mg daily for high triglycerides.
Mr. X is here today for a follow up visit. His A1C is 6.5%, weight 285 lbs, triglyceride 531 mg/dL, C-peptide 0.85 nmol/L, and BMI 33.8 kg/m2.
He states adherence to his medication regimen. He is still taking 50 units of U-500 insulin twice a day for his glycemic control due to his high insulin requirement. Due to his C-peptide levels, he is considered to have type 2 diabetes mellitus.
According to the 2017 AACE/ACE consensus statement on the comprehensive type 2 diabetes management, which one of the following recommendations for the use of GLP-1 agonist could be considered for this patient?
Show Answer
The correct answer is: C. He is a good candidate for GLP-1 agonist therapy due to its weight-lowering property.
The patient was diagnosed with type 1 diabetes but due to his elevated C-peptide is now classified as a type 2. Although the patient states adherence to his medication regimen and lifestyle modifications and his A1C is at goal, he did not achieve his weight reduction goal and his U-500 insulin dose stayed very high due to his insulin resistance.
According to 2017 AACE/ACE consensus statement, patients whose insulin regimens fail to provide adequate glycemic control may benefit from the addition of a GLP-1 receptor agonist. GLP-1 receptor agonists have vigorous A1C-lowering properties and are usually accompanied with weight loss and blood pressure reductions.
Answers A, B, and D are not the best options for this patient. Option A states that GLP-1 agonists do not have promising effects on A1C. However, GLP-1 agonists are recommended by AACE/ACE for effectively lowering A1C levels. Answer B claims that the use of GLP-1 agonists is contraindicated in patients with history of pancreatitis. But according to the AACE/ACE consensus statement, no studies have confirmed that incretin agents cause pancreatitis. However, GLP-1 receptor agonists should be used cautiously in patients with a history of pancreatitis and discontinued if acute pancreatitis develops. Answer D states that GLP-1 agonists increase the risk of hypoglycemia which is contrary to the AACE/ACE consensus statement that the risk of hypoglycemia with GLP-1 receptor ago¬nists is low because they decrease fluctuation in both fasting and post prandial glucose levels.
References
Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm - 2017 executive summary. Endocr Pract 2017;23:207-38.
Log in to MyACC
