Week 6 Discussion: Patient With Polydipsia and Weight Gain

Nonpharmacologic Treatments Recommended to FM

Given FM's diagnosis of new-onset type 2 diabetes mellitus (T2DM), lifestyle modifications are critical. The following nonpharmacologic strategies are recommended:

• Medical nutrition therapy (MNT): A referral to a registered dietitian is recommended to develop a meal plan that supports weight loss and glycemic control. FM should be educated on carbohydrate counting and choosing low-glycemic index foods (American Diabetes Association [ADA], 2024).
• Physical activity: FM should engage in at least 150 minutes per week of moderate-intensity aerobic activity and strength training twice weekly, as tolerated (ADA, 2024).
• Behavioral counseling: Counseling or behavioral therapy is advised to address emotional eating and mental health, especially in light of FM’s reported loneliness and depression during the pandemic.
• Self-monitoring: FM should be educated on how to monitor his blood glucose at home, given his elevated A1c and random glucose levels.

Pharmacologic Treatments Recommended or Avoided

Due to FM's significant hyperglycemia (random glucose of 358 mg/dL and A1c of 11.4%), pharmacologic therapy is indicated.

• Recommended:
• Metformin is the first-line pharmacologic agent unless contraindicated. It enhances insulin sensitivity and has a favorable weight profile (ADA, 2024).
• GLP-1 receptor agonists (e.g., semaglutide) or SGLT2 inhibitors (e.g., empagliflozin) may be added for further glycemic control, weight reduction, and cardiovascular benefit. These classes are advantageous for patients with obesity and elevated cardiovascular risk (Davies et al., 2022).
• Avoided:
• Sulfonylureas and insulin may promote weight gain and hypoglycemia and may not be ideal as initial treatments unless FM is experiencing severe hyperglycemia symptoms.
• Thiazide diuretics (e.g., hydrochlorothiazide) can worsen glycemic control. Switching to a more metabolically favorable antihypertensive should be considered (ADA, 2024).

Additional Laboratory Tests Recommended

• Fasting lipid panel: To assess cardiovascular risk and guide statin therapy.
• Serum creatinine and estimated glomerular filtration rate (eGFR): To evaluate renal function before initiating metformin or SGLT2 inhibitors.
• Liver function tests: Baseline testing is necessary prior to initiating some antidiabetic agents.
• Urine albumin-to-creatinine ratio (UACR): To screen for diabetic nephropathy.
• Thyroid-stimulating hormone (TSH): To rule out thyroid dysfunction, which can impact weight and glycemic control.

References

American Diabetes Association. (2024). Standards of care in diabetes—2024. Diabetes Care, 47(Supplement 1), S1–S200. https://doi.org/10.2337/dc24-S001

Davies, M. J., Aroda, V. R., Collins, B. S., Gabbay, R. A., Green, J., Maruthur, N. M., … & Wexler, D. J. (2022). Management of hyperglycemia in type 2 diabetes, 2022: A consensus report by the ADA and the European Association for the Study of Diabetes (EASD). Diabetes Care, 45(11), 2753–2786. https://doi.org/10.2337/dci22-0034