• List current goals and testing frequency in patients with diabetes mellitus (DM) (A1C, BP, Cholesterol).
• Discuss when (and when not) to intensify medication regimens to achieve control.
• Describe a short and practical way to assess adherence.

Jeroan J. Allison, MD
Vice Chair and Professor, Department of Quantitative Health Sciences
University of Massachusetts School of Medicine
Worcester, MA

Formerly, Professor, Division of Continuing Medical Education
University of Alabama at Birmingham
Birmingham, AL

Carlos Estrada, MD
Associate Professor,
Division of General Internal Medicine

Fernando Ovalle, MD
Associate Professor
Division of Endocrinology, Diabetes & Metabolism

Monika Safford, MD
Associate Professor,
Division of Preventive Medicine

University of Alabama School of Medicine, UAB
Birmingham, Alabama

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

Diabetes affects approximately 23.6 million people (7.8% of the population) across the U.S. and is the primary diagnosis in approximately 28.6 million ambulatory care visits each year.[1,2] Management of diabetes in the primary care setting is an important, but often challenging, responsibility for many physicians and health care providers. Evidence-based guidelines for diagnosis and management of diabetes have been disseminated by the American Diabetes Association.[3] The current module is the third in a series designed to provide case-based examples of common patient scenarios and the associated management strategies.

Ms. Murray, a 57-year-old African-American female, comes to see you for a routine visit. Initially, her diabetes was poorly controlled. While taking metformin and rosiglitazone, she lost 30 pounds and maintained an A1c below 7%. Over the past 12 months, she has regained 20 pounds and her A1c rose to 8.6% 3 months ago. Since her last visit 3 months ago, she has tried her best to improve her diet and exercise, but you see that she actually gained 3 more pounds since then. The A1c from this morning is 8.2%. Aside from being frustrated about not being able to lose weight, she feels fine. She rarely misses taking any of her medications.

Past Medical History:

• Type 2 diabetes for 12 years (with complications: sensory polyneuropathy, retinopathy, stage 2 CKD with microalbuminuria)
• Hypertension
• Dyslipidemia
• Obesity

Medications:

• Metformin 1000 mg bid
• Rosiglitazone 8 mg qd
• Glimepiride 4 mg qd
• Lisinopril 40 mg qd
• HCTZ 25 mg qd
• Metoprolol 50 mg bid
• Simvastatin 40 mg qd
• Ezetimibe 10 mg qd
• ASA 81 mg qd

Her capillary blood glucose in your office is 192mg/dL. On exam, her weight is 205 lbs; height 64 in, BP 128/78, HR 68.