Interactive diabetes case 16: A 61-year-old patient with uncontrolled type 2 diabetes on two oral agents – A1

ANSWER — Incorrect.

In general, the addition of a third oral antidiabetic agent in a patient with a glycated hemoglobin (A1C) value of 9.2 percent is unlikely to achieve the goal of reducing the A1C to <7.0 percent. Pioglitazone, a thiazolidinedione, is a peroxisome proliferator-activated receptor gamma (PPAR-gamma) modulator. It reduces the A1C value by 0.5 to 1.4 percent when used as monotherapy. It is unlikely to reduce the A1C by more than this in a patient who is taking two other oral agents. (See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Dual agent failure'.)

The thiazolidinediones are difficult to use because their effect on glucose levels and A1C values may not be apparent for two to three months. The use of three oral agents is often more expensive than insulin plus metformin when a less expensive insulin such as NPH is used. These agents cause weight gain and fluid retention and increase the risk of congestive heart failure. They should not be used in patients with a history of congestive heart failure or chronic kidney disease. Pioglitazone causes an increased risk of fractures of the upper arms, hands, and feet, particularly in female patients with diabetes. Rosiglitazone, another agent in the same class, may cause an increased risk of myocardial infarction. For all these reasons, thiazolidinediones are not recommended for the treatment of diabetes. (See "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects'.)

Return to the beginning to try again. (See "Interactive diabetes case 16: A 61-year-old patient with uncontrolled type 2 diabetes on two oral agents".)