I have a patient with type 2 diabetes who is on a maximum dose of oral agents. However, his blood glucose monitoring shows an increasing trend of blood sugars. What next?

If your patient is taking the maximum amount of oral hypoglycemic agents, the next obvious choice would be to treat with insulin. However, I guess I would ask which oral medications are being taken. It is now very common in the U.S. for patients with type�2 diabetes to be on a combination of multiple oral medications.

In addition, it would be helpful to have a more quantitative and detailed indicator of blood sugar elevation. If the sugars are markedly elevated above target blood sugars, and if the hemoglobin A1c is greater than 1% above the normal range, insulin would still likely be the next best therapy. The type of insulin therapy could range from NPH or Lantus as the long-acting insulin with Humalog. NovoLog, or Regular as the short-acting insulin.

JTL

[Editor’s comment: Also, if the patient is indeed on maximal doses of several diabetes pills, there is a decision to be made about insulin therapy: whether to add insulin therapy while maintaining the oral agents (in which case a single injection of insulin is usually added), or switching completely (discontinuing the pills when starting multiple injections). Either way is acceptable, and again the choice depends on several factors.

WWQ]