Targets for Diabetes Control
According to the American Diabetes Association (ADA), the set target for HbA1c recommended should be less than 7.0%. Additionally, the fasting glucose should be below 130 mg/dl. Moreover, a patient’s postprandial glucose should not exceed 180 mg/dl. As long as effects such as severe hypoglycemia can be avoided, those patients with long life expectancy and no cardiovascular diseases can work with a more ambitious HbA1c target of 6.0-6.5% is suitable. Conversely, if the patient has a history of severe hypoglycemia then a target of 7.5-8.0% is appropriate. This target also works well with those with short life expectancy, comorbidities and those who could not reach lower HbA1c levels after several diabetes medications and broad diabetes self-management education. According to the patient’s profile, her HbA1c levels should be less than 7.0%. This value can even eventually be 6.0-6.5%.
Assessment
By using Metformin, her HbA1c has shown significant improvement although the HbA1c is way above the limit of 7.0%. Additionally, due to the patient’s dietary indiscretions, her fasting and postprandial glucose levels remain elevated. Therefore, the factors that lead to hyperglycemia in this patient are obesity, inadequate exercise, and dietary reasons. Furthermore, there are no signs of any acute illness that may result in her suffering from hyperglycemia. Still, depending on the formulation, the adult’s daily dose of metformin recommended is 2000-2500 mg and she already uses 2000 mg, then it implies little improvement can be achieved by supplementing the dose by the remaining 500 mg.
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Plan
One of the strategies is the patient is referred to a diabetes support and education class where she receives counseling on some daily life routine modifications that will make improvements in her dietary choices and enhance her physical exercise activities (Evert,2013). For instance, statistics show that 8.6% of first-year diabetic patients in the look AHEAD study’s intensive lifestyle intervention arm lost their weight. Specifically, the look AHEAD study’s diabetic individuals showed a reduction of fasting glucose from 152 mg/dl to 130 mg/dl while HbA1c reduced from 7.3% to 6.6% (Wadden, 2014).
Therefore if there is the availability of a similar intensive program, she should be enrolled. Additionally, since metformin medication alone does not impact a significant HbA1c in this patient, then metformin should be supplemented with other beneficial medications recommended by American Diabetes Association such as Insulin and Dipeptidyl peptidase (DPP)-4 inhibitor. Additional medications that can be used also include Glucagon-like peptide (GLP)-1 agonist, Thiazolidinedione and Sulfonylurea.
Despite these medications acting as a supplement, the choice of class of medication to use will depend on a number of factors. For example, the patient’s preferences (routine or any viable factor), the medications efficiency to minimize the HbA1c levels, capabilities to cause hypoglycemia, the probability of inducing weight gain, its side effects, and the cost associated with acquiring the medication (Inzucchi, 2013).
Overall, the patient can be subjected to another diabetes medication but should avoid the injectable medications, that is, since she is already obese, factors and medication choices that would further induce weight gain should be avoided. After commencing the medication and lifestyle changes program, she should be subjected to a follow-up Hba1c levels test after a period of three months to ascertain if the new routine and medication choice are effective.
References
Evert, A., Boucher, J., Cypress, M., Dunbar, S., Franz, M., & Mayer-Davis, E. et al. (2013). Nutrition Therapy Recommendations for the Management of Adults With Diabetes. Diabetes Care , 36 (11), 3821-3842. doi: 10.2337/dc13-2042
Inzucchi, S., Bergenstal, R., & Buse, J. et al. (2013). Management of hyperglycemia in type 2 diabetes: a patient-centered approach. Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2012;35:1364-1379. Diabetes Care , 36 (2), 490-490. doi: 10.2337/dc13-er02
Wadden, T. (2014). Impact of Intensive Lifestyle Intervention on Depression and Health-Related Quality of Life in Type 2 Diabetes: The Look AHEAD Trial. Diabetes Care , 37 (6), 1544-1553. doi: 10.2337/dc13-1928
