Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 44-year-old man is evaluated for management of type 2 diabetes mellitus. He was diagnosed with diabetes 6 months ago after being admitted to the hospital with diabetic ketoacidosis. He was discharged from the hospital on a basal and preprandial insulin regimen. Medications are regular insulin before meals and neutral protamine Hagedorn (NPH) insulin at bedtime. He completed diabetes education and nutrition classes and has been adherent with lifestyle modifications. His insulin doses have been decreased gradually over the last 4 to 5 months. His most recent HbA1c level is 6.7%. Blood glucose values from his log book average 130 mg/dL (7.2 mmol/L).
On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 128/68 mm Hg, and pulse rate is 72/min. BMI is 30. His physical examination is unremarkable.
Laboratory studies at the time of hospital admission show a fasting glucose of 825 mg/dL (45.8 mmol/L), negative antibodies to glutamic acid decarboxylase 65 (GAD-65) and islet antigen 2 (IA-2), and a fasting C-peptide of 0.5 ng/mL (0.16 nmol/L) (normal range: 0.8-3.1 ng/mL [0.26-1.03 nmol/L]).
Which of the following is the most appropriate next step in his management?
A. Discontinue current insulin regimen, initiate sliding-scale insulin
B. Discontinue insulin, initiate metformin
C. Repeat measurement of antibodies to glutamic acid decarboxylase 65 and islet antigen 2
D. Repeat measurement of fasting C-peptide and glucose levels
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