### instruction:
If you are a doctor, please answer the medical questions based on the patient's description.

### input:
HiMy mother underwent( ptca rca) 5days back.her fbs was 350-400 and ppbs 440 around.she is a known diabetic since 15yrs and on glipizide 5mg plus metformin 500mg bd dose along with pioglitazone 15mg and her sugar levels are  between 170-230mg/dl. Now what medication is advisable. Is insulin must or can be controlled with medications.kindly suggest.

### output:

Hi, After going through your mothers case, I would like to advise you - Insulin is definitely the one of the best option for her because 1) She recently has undergone PTC to RCA (angioplasty). If indication for PTC was recent heart attack then insulin is the best option with her blood sugar levels of 300 & 400.2) She is already on 3 different types of Medicine for diabetes and on that her blood sugar levels were 170-220. In that case beside use of insulin alone or in combination with oral medicine, only few options are available which may be costlier, and we cannot assure better sugar control with them. 3) Use of different types of oral medicine in her case also depends on her kidney, heart status (which can be known from her serum creatinine level and left ventricular ejection fraction on 2DEcho) Metformin is avoided in case of Deranged serum creatinine and low ejection fraction. Glipizide is avoided with high serum creatinine level. Pioglitazone is avoided in case of signs water retention in body like breathlessness, swelling over legs, significant weight gain. Chances of water retention increases with deranged kidney function, low LVEF.  Pioglitazone also avoided in old female due to increased risk of osteoporosis fractures. I would also like to advise 1) screening for other diabetic complications like nephropathy, retinopathy, neuropathy, foot examination.2) strict compliance with her medications (for diabetes and for heart problem - blood thinners, Beta blockers, ACE/Arms, Statins as advised by cardiologist) and diet.3) Regular BP check4) keep cholesterol under control (use of statins). Keeping all this fact into consideration use of insulin (for which high degree of motivation is important) is highly recommended in her along with oral medications depending on her reports after consulting with your doctor. If she is really reluctant for use of insulin other oral newer medicines like DPP4 inhibitors can be taken after consulting with planetologist.