What is the most appropriate treatment for a 17-year-old male with type 2 diabetes (T2D), presenting with fatigue, significant weight loss, polyuria, polydipsia, and nausea, with a capillary blood glucose level indicating hyperglycemia, a hemoglobin A1c (HbA1c) level of 11.5% indicating poor glycemic control, and a history of non-adherence to metformin (metformin) therapy?

From the Guidelines

The most appropriate treatment for this 17-year-old male with poorly controlled type 2 diabetes would be to restart metformin and add basal insulin therapy. The patient should resume metformin at a dose of 500-1000 mg twice daily with meals, and begin basal insulin (such as insulin glargine or detemir) at approximately 0.2-0.3 units/kg/day, as recommended by the most recent guidelines 1. This combination therapy is indicated because the patient has significant hyperglycemia (blood glucose 348 mg/dL, HbA1c 11.5%) with symptoms of polyuria, polydipsia, weight loss, and fatigue. While his presentation shows marked hyperglycemia, the absence of ketones and acidosis indicates he is not in diabetic ketoacidosis. The patient previously discontinued his metformin, which likely contributed to his current poor glycemic control. Metformin works by decreasing hepatic glucose production and improving insulin sensitivity, while basal insulin will help control fasting glucose levels.

The patient's current presentation, with a blood glucose level of 348 mg/dL and an HbA1c of 11.5%, meets the criteria for initiating basal insulin therapy, as outlined in the guidelines 1. The guidelines recommend initiating basal insulin therapy in patients with type 2 diabetes who have marked hyperglycemia (blood glucose ≥250 mg/dL) and symptoms of polyuria, polydipsia, and weight loss.

Key points to consider in the treatment plan include:

• The importance of medication adherence and regular follow-up to assess response and adjust therapy as needed
• Education on insulin administration, blood glucose monitoring (at least 2-4 times daily), and recognition of hypoglycemia symptoms
• Monitoring for potential side effects of metformin, such as gastrointestinal intolerance and vitamin B12 deficiency
• Regular assessment of renal function, as metformin is contraindicated in patients with an estimated glomerular filtration rate <30 mL/min/1.73 m² 1.

Overall, the combination of metformin and basal insulin therapy is the most appropriate treatment for this patient, given his significant hyperglycemia and symptoms of polyuria, polydipsia, and weight loss, as supported by the most recent guidelines 1.

From the FDA Drug Label

Metformin hydrochloride tablets has been shown to effectively lower glucose levels in children (ages 10 to16 years) with type 2 diabetes. The most appropriate treatment for the 17-year-old male with type 2 diabetes would be to restart metformin as it has been shown to be effective in lowering glucose levels in children with type 2 diabetes, including those around his age.

• The patient had been taking metformin previously, but stopped six months ago.
• His current symptoms, such as fatigue, weight loss, excessive urination, thirst, and nausea, along with a high capillary blood glucose level and hemoglobin A1c, indicate that his diabetes is not well-controlled.
• Given his age and the fact that metformin has been effective in pediatric patients with type 2 diabetes, metformin would be a suitable treatment option for him 2.
• It is essential to monitor his kidney function and adjust the dosage as needed, as well as educate him on the importance of adhering to the prescribed treatment regimen and lifestyle modifications to manage his diabetes effectively 2.

From the Research

Patient Presentation and History

The patient is a 17-year-old male with a history of type 2 diabetes, presenting with fatigue, a 15-pound weight loss in the past month, excessive and frequent urination, thirst, and nausea. He had been taking metformin but stopped six months ago.

Current Clinical Findings

• Weight: 205 pounds
• Blood pressure: 130/78
• Pulse rate: 90
• Temperature: 98.6
• Capillary blood glucose level: 348
• Hemoglobin A1c: 11.5%
• Serum ketones: Negative
• Urinalysis: 3+ glucose with concentrated urine, otherwise normal

Treatment Considerations

Given the patient's history and current clinical findings, the most appropriate treatment should aim at achieving better glycemic control.

• Metformin is typically the first-line therapy for type 2 diabetes due to its efficacy, safety, low cost, and cardiovascular benefits 3.
• However, the patient has stopped taking metformin, and his current glycemic control is poor, suggesting the need for either resuming metformin or adding another agent.
• Other options like sulfonylureas, GLP-1 receptor agonists, DPP-4 inhibitors (e.g., alogliptin), and SGLT2 inhibitors (e.g., dapagliflozin) could be considered based on their efficacy and safety profiles 4, 5, 6.
• The choice between these agents should consider factors like the patient's renal function, potential for hypoglycemia, weight effects, and cardiovascular benefits.

Specific Treatment Options

• Metformin Resumption: Given its established benefits and the patient's previous use, resuming metformin could be a reasonable first step, adjusting the dose according to renal function if necessary 7.
• Addition of Other Agents: If metformin alone is insufficient or not tolerated, adding another agent like alogliptin or dapagliflozin could be considered for their glycemic efficacy and potential benefits on weight and cardiovascular outcomes 4, 5, 6.

Decision Making

The decision should be based on the patient's specific clinical profile, including his ability to tolerate medications, potential drug interactions, and his preferences. Given the patient's young age and the absence of information on renal function or other comorbidities, careful consideration of the potential benefits and risks of each treatment option is necessary.