residual beta cell function and thus simplify her hypoglycaemic therapy in the medium to long term. The initial drug of first choice would be metformin. There are theoretical grounds in some patients (see above) for starting with a glitazone drug if the predominant abnormality is insulin resistance or if the major abnormality of glucose is in the post-prandial state. There is no ready access to measures of these abnormalities in routine clinical practice. The dose of metformin may be gradually adjusted, according to her response, over a period of about three months. If she remained hyperglycaemic, add-in therapy with either sulphonylurea or glitazone should be considered. For most patients, sulphonylurea seems a logical choice since the patient would then be taking an insulin sensitizer and a secretagogue. However, there is strong evidence that metformin and glita-zone together are beneficial, particularly in patients with insulin resistance as the major abnormality.
This woman has multiple features of the metabolic syndrome and is at high risk of both micro- and macrovascular complications. Tight glycaemic control will help preserve her
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