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April 3, 2002

Treatment Decisions for Type 2 Diabetes

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthor

JAMA. 2002;287(13):1646-1648. doi:10.1001/jama.287.13.1645

To the Editor: I disagree with 3 of the assertions that Dr Holmboe makes in his Clinical Applications article1 about treatment of type 2 diabetes. First, he describes a patient with a random plasma glucose concentration of 480 mg/dL (27 mmol/L) and states that such a patient would require insulin. I believe that this patient would almost certainly respond to high doses of a sulfonylurea agent. I have treated more than 100 symptomatic patients with glucose levels of this magnitude, many of whom have had ketosis, a few with slightly lowered bicarbonate levels (down to 16 meq/L), and a fair number with significant weight loss. More than 90% of them do not require insulin. After 4 months, 6 of 55 patients2 were lost to follow-up (4 patients had lost their health maintenance organization insurance and 2 would not comply with the recommended follow-up). Of the remaining 49 patients, 6 continued taking a maximal dose of glyburide, 29 were taking a submaximal dose, 11 were treated with diet alone, and 3 were taking insulin. The insulin was started several weeks to several months later, when goal levels of glycemia were unmet, not as an emergency to treat the initial hyperglycemia. At the time this study was carried out, no other oral antidiabetes drugs were available in the United States. It is likely that the addition of another oral drug would have avoided the need for these 3 patients to take insulin during the 4 months of the study. Thus, one can spare the patient the rigors of immediate insulin therapy to see if he or she will respond to a high dose of a sulfonylurea agent.