Management of Type 2 Diabetes with Improved A1C from 9.0 to 8.5
The patient's current regimen of Lantus 28 units twice daily and pioglitazone 15mg should be intensified by increasing the pioglitazone dose to 30mg daily while maintaining the current insulin dose, as the A1C of 8.5% remains above the target goal despite improvement. 1
Current Status Assessment
- The patient has shown improvement in A1C from 9.0% to 8.5% on Lantus 28 units twice daily and pioglitazone 15mg, indicating partial response to therapy 1
- Fasting blood sugars of 130-140 mg/dL are above the recommended target range of 80-130 mg/dL 1
- Current A1C of 8.5% corresponds to an estimated average glucose of approximately 197 mg/dL, indicating suboptimal control 1
Recommended Treatment Modifications
Pioglitazone Adjustment
- Increase pioglitazone from 15mg to 30mg daily to maximize insulin-sensitizing effects 2, 3
- Pioglitazone at higher doses (30mg) has shown greater A1C reduction when used in combination with insulin therapy 3
- The combination of insulin with pioglitazone can reduce A1C by 0.6%-2.1%, with higher baseline A1C values showing larger reductions 3
Insulin Management
- Maintain current Lantus (insulin glargine) dose of 28 units twice daily for now 1, 4
- Reassess in 3 months to determine if basal insulin dose needs adjustment based on fasting glucose response 1, 5
- Consider adding a GLP-1 receptor agonist if A1C remains above target after optimizing pioglitazone dose 1, 6
Monitoring Plan
- Check A1C in 3 months to evaluate response to therapy 1
- Monitor fasting blood glucose daily, targeting 80-130 mg/dL 1
- Watch for signs of hypoglycemia, especially in the first 1-2 months after increasing pioglitazone dose 3
- Monitor for fluid retention and edema, which can occur in 10-20% of patients on combination insulin and pioglitazone therapy 3
Rationale for Recommendation
- The current A1C of 8.5% remains above the recommended target of <7.0% for most adults with diabetes 1
- Pioglitazone has an additive effect when combined with insulin by improving insulin sensitivity through different mechanisms 2, 3
- Increasing pioglitazone dose before further increasing insulin can help minimize weight gain and hypoglycemia risk associated with higher insulin doses 3
- The American Diabetes Association recommends reassessing and modifying treatment regularly (every 3-6 months) when A1C remains above target 1
Common Pitfalls to Avoid
- Avoiding treatment intensification when A1C is improving but still above target can lead to prolonged hyperglycemia and increased risk of complications 1
- Increasing insulin dose without maximizing oral agent efficacy may lead to unnecessary hypoglycemia risk and weight gain 5, 4
- Failing to monitor for fluid retention when using pioglitazone with insulin, especially at higher doses 3
- Not considering the addition of a GLP-1 receptor agonist, which can have additive effects with both insulin and thiazolidinediones 1, 7
If the patient's A1C does not improve to <8% after 3 months on increased pioglitazone dose, consider adding a GLP-1 receptor agonist or adjusting the insulin regimen by adding prandial insulin with the largest meal 1, 5.