This article is more than 5 years old. Information may no longer be current.
Diabetes Case Challenge: Are all thiazolidinediones risky?
Click Here to Manage Email Alerts
A 58-year-old Hispanic man came to see me in follow-up for a routine visit for type 2 diabetes. His diabetes had been well-controlled in the past (HbA1c of 7.0) on a regimen of metformin, pioglitazone and glimepiride. He tolerated this well.
However, when the patient saw his primary care physician one week prior to seeing me, he was taken off pioglitazone. The patient had voiced concerns about media reports that thiazolidinediones (TZDs) may increase his risk of MI.
The patient proudly showed me his blood glucose log, which by and large demonstrated sugars between 100 mg/dL and 150 mg/dL with occasional excursions above 200 mg/dL.
His history consisted of hypertension, hyperlipidemia, erectile dysfunction and diabetic neuropathy. Review of systems was unremarkable. The patient quit smoking one year prior and consumed three drinks per week.
|
|
Medications included glimepiride 4 mg daily, metformin 1,000 mg twice a day, lisinopril 5 mg daily, aspirin 81 mg daily and tadalafil (Cialis, Eli Lilly and Co.) as needed.
On physical exam, this was a normal-weight Hispanic man in no acute distress, BP 100 mm Hg/70 mm Hg, heart rate 76, 165 lbs, 5’8”. Exam was remarkable for decreased sense of vibration at both ankles, but otherwise normal.
What is the best course of action for this patient, and why?
A. Continue his current glycemic regimen of glimepiride and metformin because it seems to be working.
B. Reassure the patient that pioglitazone will not increase his risk for MI and explain that his blood glucose levels will eventually rise with his current regimen.
C. Start regular insulin sliding scale.
D. Double the dose of glimepiride.
The answer is B. This patient is one of many whose TZD was discontinued after a hotly discussed and publicized meta-analysis suggesting increased CV morbidity and mortality with rosiglitazone (Avandia, GlaxoSmithKline). Other analyses have not found such a link. Pioglitazone, just like rosiglitazone, is known to carry an increased risk of congestive HF, but it has not been found to increase risk for ischemic CV events. Nonetheless, TZDs have often been discontinued, despite providing good glycemic control.
This patient appears to have decent blood glucose levels, despite the discontinuation of pioglitazone. PPAR-gamma agonists, however, have delayed onset and cessation of action, and it will take several weeks to see blood glucose levels trend up.
Doubling the dose of glimepride may generate some improvement in blood glucose levels, but as with other agents, doubling the dose does not generate a doubled effect and cannot replace another agent from a different class.
Finally, regular insulin sliding scale is a poor management choice in any situation; it is merely reactive and therefore predisposes patients to hypo- and hyperglycemia.
Ronald Tamler, MD, PhD, MBA, is Instructor, Division of Endocrinology, Mount Sinai School of Medicine. Diabetes Case Challenge will appear periodically in Cardiology Today. Send your ideas to: editor@cardiologytoday.com.
For more information:
- Nissen SE. N Engl J Med. 2007; 356:2457-2471.
- Mannucci E. Diabetes Obes Metab. 2008;10:1221-1238.