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Clinical Crossroads | Clinician's Corner

A 74-Year-Old Woman With Diabetes

Martin J. Abrahamson, MB, CHB, Discussant
JAMA. 2007;297(2):196-204. doi:10.1001/jama.297.2.196.
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Ms M, a 74-year-old woman with type 2 diabetes of 6 years' duration, has a glycated hemoglobin (HbA1C) value of 7.4% despite taking 3 oral antidiabetic medications, as well as coexistent hypertension and abdominal obesity. She has no known microvascular or macrovascular complications of diabetes and is otherwise healthy. She is reluctant to commence insulin treatment as she dislikes the idea of injections and wonders if there are any alternate options if she is to get her HbA1C value below 7%. The natural history of type 2 diabetes, reasons why many patients begin requiring insulin over time, rationale for tight glycemic control, and therapeutic options for Ms M are discussed.

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Figure. Schematic of Progression From Normal Glucose Tolerance to Impaired Glucose Tolerance and Type 2 Diabetes Mellitus
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*Visceral fat accumulation is associated with altered secretion of adipocytokines that impair insulin sensitivity (eg, increased tumor necrosis factor α, plasminogen activator inhibitor 1, and interleukin 6, and decreased adiponectin), and with increased free fatty acid production.

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