Case Studies

Sample case study: SF

SF is a 54-year-old retired school teacher and mother of two who has had type 2 diabetes for 12 years. She is currently using basal insulin plus other oral antihyperglycemic agents. Her A1c is 8.1%, and her fasting plasma glucose is around 140 mg/dL. She is concerned about low blood sugar since this has been an issue in the past; she is wary of further titrating her insulin despite her blood sugars not being within target range.

  1. What questions would you ask and additional information would you like to collect regarding her hypoglycemia concerns?
    1. Other medications
    2. Barriers
    3. Self-management skills
  1. What changes would you consider making to her current treatment plan?
    1. Discontinuing medications with a high hypoglycemia risk profile (ie, sulfonylureas)
    2. Employing the newer-generation basal insulins
    3. Using GLP-1 RAs and basal insulin combinations
  1. How would you initiate and titrate some of the newer agents in this patient?
    1. Newer generation basal insulins
    2. GLP-1 RAs and basal insulin combinations
  1. What counseling points and monitoring parameters would be important to discuss with her regarding her new treatment plan?
    1. Newer generation basal insulins
    2. GLP-1 RAs and basal insulin combinations


Sample case study: NP

NP is a 44-year-old man with established atherosclerotic cardiovascular disease (ASCVD) and newly diagnosed type 2 diabetes. The patient was initiated on metformin therapy (up-titrated to maximum dose) and presents to you for a follow-up after 3 months. His A1c is 8.2%, down from 9.1%. He reports an 8-pound weight loss after implementing lifestyle changes and continues to focus on losing weight. The patient’s other conditions include hypertension, dyslipidemia, depression, and obesity. The patient’s current medication list includes lisinopril 5 mg daily, aspirin 81 mg daily, rosuvastatin 20 mg daily, and a multivitamin every morning.

A1c = 8.2%
Height = 68 inches; waist circumference = 41 inches
Weight = 223 lb; BMI = 34 kg/m2
BP = 138/86 mm Hg; HR = 74 bpm
Na = 144 mg/dL
K = 4.6 mg/dL
SCr = 1.4 mg/dL
eGFR = >60mL/min
MAB/Cr ratio = 145
Liver-function tests = WNL


  1. What additional antihyperglycemic agent(s) would be appropriate for this patient if lifestyle modifications plus metformin therapy are not enough? Discuss the pros and cons of various newer agents with a focus on efficacy and safety.
    1. GLP-1 RAs
    2. SGLT-2 inhibitor
  1. Does the presence of ASCVD influence your treatment decision? If so, why?
  1. What are the differences and similarities between the 2018 ADA and AACE guidelines? Discuss goals, treatment approaches, etc.
    1. GLP-1 RAs
    2. SGLT-2 inhibitor
  1. What other factors do you consider when initiating or adding antihyperglycemic agents?
    1. Hypoglycemia profile
    2. Weight profile
    3. Cardiovascular data
    4. Renal data