Lucille is 37 years old and has had type 2 diabetes for 7 years. Her A1C has been creeping up for several years. Her BMI has been fluctuating around 38 kg/m2. She is presently taking the maximum doses of metformin and a sulfonylurea (SU). DPP-4 inhibitors, GLP-1 receptor agonists and SGLT2 inhibitors have been avoided as she may desire another pregnancy. She is attending a local weight support group sessions. She has been encouraged to do 150 minutes of weekly aerobic exercise. Her A1C is now at 8.2% and her fasting blood glucose, on home monitoring, averages 12 mmol/L. She is frightened as several family members have had diabetes complications. She is now ready for insulin.
Question 1: What would you recommend for Lucille?
|Stop her metformin and SU and begin a bedtime intermediate or long-acting insulin.
|Continue her metformin and SU but add a fixed dose of 10 units of bedtime intermediate or long acting-insulin.
|Continue her metformin and SU, begin a bedtime intermediate or long-acting insulin, teaching Lucille how to titrate the insulin based on her pre-breakfast BG.
|Stop metformin and SU and begin a premixed insulin before breakfast and supper.
References for Lucille:
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