GLP-1 Agonist Use in a Patient with High Insulin Resistance
Mr. X is a 31-year-old male who has been diagnosed with type 1 diabetes since the age of 14. He has a history of pancreatitis in 2008. He came to the clinic a year ago at age 30 with A1C = 9.1%, weight = 290.40 lbs and body mass index (BMI) = 36.79 kg/m2. He was on an insulin pump with 138 units basal and 22 units pre-prandial dose. He was started on metformin 1000 mg twice a day and dapaglifozin 10 mg daily. His insulin was switched to U-500 25 units twice a day which was increased to 50 units twice a day due to his high insulin resistance. He was also started on atorvastatin 20 mg daily, fenofibrate 54 mg daily and pioglitazone 15 mg daily for high triglycerides.
Mr. X is here today for a follow up visit. His A1C is 6.5%, weight 285 lbs, triglyceride 531 mg/dL, C-peptide 0.85 nmol/L, and BMI 33.8 kg/m2.
He states adherence to his medication regimen. He is still taking 50 units of U-500 insulin twice a day for his glycemic control due to his high insulin requirement. Due to his C-peptide levels, he is considered to have type 2 diabetes mellitus.
According to the 2017 AACE/ACE consensus statement on the comprehensive type 2 diabetes management, which one of the following recommendations for the use of GLP-1 agonist could be considered for this patient?
Show Answer
The correct answer is: C. He is a good candidate for GLP-1 agonist therapy due to its weight-lowering property.
The patient was diagnosed with type 1 diabetes but due to his elevated C-peptide is now classified as a type 2. Although the patient states adherence to his medication regimen and lifestyle modifications and his A1C is at goal, he did not achieve his weight reduction goal and his U-500 insulin dose stayed very high due to his insulin resistance.
According to 2017 AACE/ACE consensus statement, patients whose insulin regimens fail to provide adequate glycemic control may benefit from the addition of a GLP-1 receptor agonist. GLP-1 receptor agonists have vigorous A1C-lowering properties and are usually accompanied with weight loss and blood pressure reductions.
Answers A, B, and D are not the best options for this patient. Option A states that GLP-1 agonists do not have promising effects on A1C. However, GLP-1 agonists are recommended by AACE/ACE for effectively lowering A1C levels. Answer B claims that the use of GLP-1 agonists is contraindicated in patients with history of pancreatitis. But according to the AACE/ACE consensus statement, no studies have confirmed that incretin agents cause pancreatitis. However, GLP-1 receptor agonists should be used cautiously in patients with a history of pancreatitis and discontinued if acute pancreatitis develops. Answer D states that GLP-1 agonists increase the risk of hypoglycemia which is contrary to the AACE/ACE consensus statement that the risk of hypoglycemia with GLP-1 receptor ago¬nists is low because they decrease fluctuation in both fasting and post prandial glucose levels.
References
- Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm - 2017 executive summary. Endocr Pract 2017;23:207-38.
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