Diabetes Mellitus
The patient returns over time. Make your treatment decision before revealing each prescription.
Visit 1 — First OPD Consultation
46-year-old woman, BMI 29 kg/m². Polyuria and fatigue. FBS 168 mg/dL, PPBS 264 mg/dL, HbA1c 8.2%, eGFR 92.
What will you prescribe now?
Treatment decision
Start metformin 500 mg with dinner for 5–7 days, then 500 mg twice daily with meals if tolerated. If GI intolerance develops, use an extended-release preparation. Lifestyle modification: stop sugar-sweetened drinks, reduce refined carbohydrate portions, increase vegetables/protein/fibre, and aim for ≥150 min/week moderate aerobic activity plus resistance exercise 2–3 days/week.
Start metformin 500 mg with dinner for 5–7 days, then 500 mg twice daily with meals if tolerated. If GI intolerance develops, use an extended-release preparation. Lifestyle modification: stop sugar-sweetened drinks, reduce refined carbohydrate portions, increase vegetables/protein/fibre, and aim for ≥150 min/week moderate aerobic activity plus resistance exercise 2–3 days/week.
Visit 2 — Treatment Review
Two months later she is adherent and tolerating metformin. FBS 154, PPBS 238, HbA1c 8.5%.
What will you prescribe now?
Treatment decision
Titrate metformin toward 1 g twice daily as tolerated. Because she remains clearly above target, add empagliflozin 10 mg once daily if there is no contraindication; counsel regarding genital infection, hydration and sick-day withholding. Continue diet and exercise.
Titrate metformin toward 1 g twice daily as tolerated. Because she remains clearly above target, add empagliflozin 10 mg once daily if there is no contraindication; counsel regarding genital infection, hydration and sick-day withholding. Continue diet and exercise.
Visit 3 — Subsequent Decision
Three months later HbA1c is 8.0% despite metformin + empagliflozin; weight remains 79 kg and she wants meaningful weight reduction.
What will you prescribe now?
Treatment decision
Rather than adding a sulfonylurea simply to lower the number, add a GLP-1–based agent when accessible—for example semaglutide 0.25 mg SC weekly for 4 weeks, then 0.5 mg weekly, with later escalation according to response/tolerance. If marked symptomatic hyperglycaemia, catabolism or HbA1c becomes very high, move promptly to basal insulin (often 10 units nightly or 0.1–0.2 U/kg/day) and titrate to fasting glucose. A dual GIP/GLP-1 RA such as tirzepatide is another weight-favouring option where appropriate and available.
Rather than adding a sulfonylurea simply to lower the number, add a GLP-1–based agent when accessible—for example semaglutide 0.25 mg SC weekly for 4 weeks, then 0.5 mg weekly, with later escalation according to response/tolerance. If marked symptomatic hyperglycaemia, catabolism or HbA1c becomes very high, move promptly to basal insulin (often 10 units nightly or 0.1–0.2 U/kg/day) and titrate to fasting glucose. A dual GIP/GLP-1 RA such as tirzepatide is another weight-favouring option where appropriate and available.
Educational use only: Synthetic cases for clinician learning. Drug selection, dose and escalation must be individualized to the actual patient, pregnancy status, age, renal/hepatic function, interactions, contraindications, affordability, local resistance/protocols and current authoritative guidance.