Where necessary, forecast the need for insulin (4 of 4)

I often give people choices in treatment. Let’s say we have a 48-year-old patient diagnosed with type 2 diabetes 2 years ago; his disease has progressed despite lifestyle interventions and metformin treatment. His HbA1c is now 11.3% (100 mmol/mol; 278 mg/dL).

I would let the patient know that we have some options—we can either provide one medication for every 1% his HbA1c is above target, or we can start a basal insulin.

I would let the patient know that my preference is to start insulin therapy; however, I would give them a voice in the decision-making process—if the patient is strongly in favor of taking three to four additional oral medications we can do this as an alternative. In such a case I would recommend close monitoring and short-term follow-up. If an improvement is observed with oral medications (based on fingerstick glucose monitoring results for the first month) we can continue with the plan but we will have insulin ready to rescue him if required.