A 60-year-old with long-standing obesity and type 2 diabetes controlled on metformin presents with recent weight gain and rising A1c despite medication. Evaluate which next-step strategy is most justified, considering pathophysiology.

• A. Prescribe only insulin without lifestyle advice because lifestyle modification never affects glycemic control after age 50 and medications are ineffective.
• B. Intensify therapy with addition of an agent that improves insulin sensitivity (eg, GLP-1 receptor agonist or SGLT2 inhibitor if appropriate) and concurrently implement structured weight-loss interventions, because progressive insulin resistance and beta-cell stress likely explain worsening glycemia.
• C. Refer for immediate pancreatic transplant because any loss of control on metformin indicates complete beta-cell loss identical to type 1 diabetes.
• D. Discontinue all medications immediately and replace with a high-carbohydrate diet to stimulate beta cells into normal function, since drug exposure causes progressive diabetes by suppressing endogenous insulin.

Answer: (B)