The NP sees  a 44-year-old male of African ancestry with a BMI=34 kg/m2 and recently diagnosed  type 2 diabetes mellitus. He works on a rotating shift in healthcare and reports eating irregularly. He was started on metformin therapy 4 months ago, is at maximum recommended dose, and states he is tolerating the medication well. His initial A1c was 9.8%, with today’s A1c=8.7%. eGFR is within acceptable parameters and he is feeling well, stating, 

“I was so thirsty and needed to urinate all the time before I started that pill”. Physical exam reveals extensive acanthosis nigricans.  He mentions that his health insurance. “Does not pay for all that much. I’m OK with paying for the pill I am taking now, but really cannot afford expensive medicines. “ Which of the following is the most appropriate next step?

A. Prescribe weekly injectable semaglutide. 

B. Adding post-meal sliding scale rapid acting insulin.

C. Add a daily dose of pioglitazone.

D. Add glipizide on days when his eating schedule is predictable. 
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