In rural health-care settings, many patients are reluctant to use insulin. Some of these patients have had excellent results in hemoglobin A1c reduction with rosiglitazone (Avandia) or pioglitazone (Actos). If a patient does not have congestive heart failure or known ischemia, is it appropriate to prescribe Actos or Avandia to those who refuse insulin therapy?—FREEMAN JONES, MSN, APRN-FNP, Emporia, Va.

Rosiglitazone and pioglitazone are not wise alternatives for the diabetic as adjunct therapy if insulin is the best choice. Both medications increase the risk of heart failure. Rosiglitazone used for five years carries the risk of one myocardial infarction for every 37 to 52 patients. Rosiglitazone also has detrimental effects on triglycerides and LDL. It is best to optimize metformin (remember it will use the vitamin B12 stores) and then try to learn why the patient is afraid of insulin and address those issues to provide the best evidence-based care.—Maria Kidner, DNP, FNP-C (144-1)