From the Guidelines
The patient should continue their current diabetes medications, including Lantus 15 units daily, NPH insulin 10 units every morning, and pioglitazone 15 mg daily, while focusing on lifestyle modifications to improve glycemic control, as the current A1c of 9.1% is above the target range of less than 7% for most diabetic patients, putting them at risk for complications. The patient's most recent HbA1c was 9.1%, indicating suboptimal diabetes control. According to the standards of care in diabetes-2023 1, for a stable patient, the focus should be on preventing hypoglycemia and managing hyperglycemia using blood glucose testing. The patient wants to check their current A1c before making medication adjustments. They should monitor blood glucose levels when fasting, 2 hours after meals, and when experiencing symptoms. To prevent morning hypoglycemia, eating a meal at night is recommended.
Lifestyle modifications are crucial, including a healthy diet with smaller, consistent meals throughout the day, limiting carbohydrates, fats, and sugary foods while increasing vegetables and lean protein consumption. The patient last met with a registered dietitian on April 7,2025, but declined another meeting. A diabetic eye exam couldn't be completed in clinic, so an optometry referral was sent. Labs will be rechecked today, with a follow-up appointment scheduled to discuss results. The use of pioglitazone, a thiazolidinedione, has been shown to have a beneficial effect on glycemic control, with a decrease in A1C levels of 0.5-1.4 percentage points when used as monotherapy 1. However, it is essential to weigh the benefits against the potential risks, such as weight gain and fluid retention.
The patient's current insulin regimen, including Lantus and NPH insulin, is aimed at managing hyperglycemia, and according to the medical management of hyperglycemia in type 2 diabetes 1, insulin therapy can be effective in lowering A1C levels, especially when used in combination with other medications. The patient's current dose of Lantus 15 units daily is within the recommended range, and the use of glargine, such as Lantus, has been shown to reduce the risk of hypoglycemia compared to NPH insulin 1.
Overall, the patient's current treatment plan should focus on improving glycemic control through a combination of medication management and lifestyle modifications, with regular monitoring of blood glucose levels and A1c to adjust the treatment plan as needed.
From the FDA Drug Label
Table 2 Glycemic Parameters in a 26-Week Placebo-Controlled Dose-Ranging Study Placebo ACTOS 15 mg Once Daily ACTOS 30 mg Once Daily ACTOS 45 mg Once Daily TOTAL POPULATION HbA1c (%) N=79 N=79 N=85 N=76 Baseline (mean) 10.4 10.2 10.2 10.3 Change from baseline (adjusted mean+) 0.7 -0.3 -0.3 -0.9 Difference from placebo (adjusted mean+) -1.0* -1.0* -1.6*
- p ≤ 0.050 vs. placebo
The patient is currently taking pioglitazone 15 mg daily. According to the study, treatment with 15 mg of ACTOS (pioglitazone) produced statistically significant improvements in HbA1c and FPG at endpoint compared to placebo. The patient's last HbA1c was 9.1, and they would like to see what their current A1c is before making any changes. It is recommended to continue taking the current medication and recheck the labs. 2
From the Research
Patient's Current Medication Regimen
The patient is currently taking:
- Lantus 15 units daily
- Insulin NPH 10 units every morning
- Pioglitazone 15 mg tablet daily
Blood Sugar Monitoring
The patient has been advised to check his blood sugars:
- Fasting
- 2 hours after eating
- Especially when feeling symptomatic
Lifestyle Changes
The patient has been recommended to work on lifestyle changes including:
- Healthy diet
- Regular exercise
- Weight loss
- Eating consistent smaller meals throughout the day
- Avoiding carbohydrates, fats, sugary drinks/foods
- Eating more vegetables, lean meat
Comparison of Insulin Glargine and NPH Insulin
Studies have compared the safety and efficacy of insulin glargine and NPH insulin in patients with type 1 and type 2 diabetes, including:
- A study published in 2003 3 which found that insulin glargine may improve glycemic control and satisfaction in patients with type 1 diabetes
- A meta-analysis published in 2005 4 which found that insulin glargine reduces the risk of hypoglycemia compared to NPH insulin in patients with type 2 diabetes
- A study published in 2015 5 which found that switching from insulin glargine to NPH insulin resulted in more severe hypoglycemia and decreased metabolic control
- A study published in 2004 6 which found that once-daily insulin glargine was at least as effective as twice-daily NPH insulin in improving fasting glycemic control and resulted in fewer reported symptomatic hypoglycemic events
- A meta-analysis published in 2008 7 which found that insulin glargine and NPH insulin have similar glucose-lowering effects, but insulin glargine is associated with less patient-reported hypoglycemia
Follow-up Appointment
The patient has requested a follow-up appointment to discuss lab results.