Respond to the 2 following discussion posts: Citations: At least one high-level scholarly reference in APA per post from within the last 5 years.
1. [Paige Coffee] The presentation of a patient with new onset diabetes or type two Diabetes requires the advanced practice nurse to be diligent. There is a lot of education that the patient requires and needs to successfully manage their new illness. The goal should be to reach their highest level of wellness, and possibly reverse their condition. Providing all the required information at once can be overwhelming so it is important to set up a series of appointments and provide referrals to nutritionists for example to help the patient to learn and decrease their risk of atherosclerosis and cardiovascular diseases.
Initial medications that this patient can take in combination with lifestyle and diet changes will help to protect her wellness and through proper management achieve her goal of not requiring insulin injections. A first line drug that works well is metformin extended release 500mg by mouth twice daily (Micromedex, 2022). The brand name for this medication is Glucophage and its class is a biguanide. This is the first line treatment recommendation for new onset diabetics. The risks of this medication should be discussed with the patient which include diarrhea, gas, nausea, vomiting, indigestion, abdominal discomfort, anorexia, headache, rash, and ovulation reduction (Micromedex, 2022). It is important to explain this medication works by reducing the amount of hepatic glucose production and intestinal absorption and increasing the sensitivity to insulin itself (Micromedex, 2022).
When the patient returns in the following month with complaints of fatigue, dry hair and nails, constipation, and heavy irregular menstruation it is important to order the necessary lab work to create a differential diagnosis. Hyperthyroidism would not be suspected here as it typically presents with increased and or irregular heartbeat, palpitations, weight loss despite increased appetite, nervousness, anxiety, and or irritability (Hyperthyroidism – Symptoms and Causes – Mayo Clinic, 2020). The lab work that should be ordered should include a TSH, T4,T3, TGB, Auto-antibodies, thyroid ultrasound, ECG, and VBG (Hypothyroidism, 2019). Hyperthyroid would show low TSH High T3 and T4 (Hypothyroidism, 2019, Table 4.2). Hypothyroidism is the exact opposite. Initial treatment for hypothyroidism should be levothyroxine which should be started at a concentration of 1.7-15 mcg/kg/day until therapeutic dose is found (Micromedex, 2022). The mechanism of action for this medication is synthetic thyroid hormone (T4). This medication is known by brand name as Synthroid, it should be taken by mouth once daily. It is important to explain to the patient that this medication must be taken exactly as directed and that changes in health should be immediately reported, around .1 percent of the population especially older adults can have the adverse effect called myxedema coma (Hypothyroidism, 2019). They should watch for symptoms as should their family that include feeling cold and a body temperature of 95.9 or less, bradycardia or slow heart rate, low blood pressure, decreased respiratory rate, upper airway obstruction, unusual behavior, or coma (Hypothyroidism – Symptoms and Causes – Mayo Clinic, 2020).
It is important to continue to order serial lab work and patient follow-up appointments. Monitoring both the patients A1C and thyroid levels to determine that therapies are effective. The patient should be asked if they have continuing symptoms or new symptoms to determine if therapeutic levels have been achieved. Caring for people with multiple comorbidities is important to understand that they are new to these processes and treatments, and continued appointments helps to determine medication compliance and effectiveness.
References
Hyperthyroidism – symptoms and causes – mayo clinic. (2020, November 14). Mayo Clinic. Retrieved March 30, 2022, from https://www.mayoclinic.org/diseases-conditions/hyperthyroidism/symptoms-causes/syc-20373659
Hypothyroidism – symptoms and causes – mayo clinic. (2020, November 14). Mayo Clinic. Retrieved March 30, 2022, from https://www.mayoclinic.org/diseases-conditions/hypothyroidism/symptoms-causes/syc-20373659
Hypothyroidism. (2019, December 17). WikEm. Retrieved March 30, 2022, from https://wikem.org/wiki/Hypothyroidism
Micromedex. (2022, February 13). (Version 3.1.1) [Mobile app]. Google Play Store. https://www.ibm.com
2. [Nuray Gercek] Week 5: Discussion Question – Case Study
Q1. Which classes of diabetes medications are either weight neutral or cause weight loss? Please give one (1) example of a drug’s generic and trade name in that class.
The class of Biguanides: Metformin, Fortamet, Glucophage, Glumetza, Fiomet can help with weight loss due to their adverse effects of decreased appetite, nausea, and diarrhea (Rosenthal & Burchum, 2021, p.407, Table 48.9). Seifarth, Schehler, and Schneider (2012) treated 154 patients with BMI>= 27 over 6 months with Metformin and studied the effects of the treatment on weight loss. They found out that the treatment with Metformin caused a significant amount of weight loss both in insulin-sensitive and insulin-resistant patients.
Glucagon-like Peptide-1(GLP-1) Receptor Agonists (incretin mimetic) are another class of diabetic drugs that can cause weight loss. They slow down gastric emptying, suppress appetite, inhibit glucagon, and stimulate the glucose-dependent release of insulin (Rosenthal & Burchum, 2021, p. 414). Examples of drugs for this class: are Exenatide (Byetta, Bydureon, Liraglutide (Victoza), Dulaglutide (Trulicity). Looks like, since last June 2021 FDA has approved a new GLP-1 receptor agonist Semaglutide with the generic name. Wegovy and Ozempic are trade names and they are injectable, while Rybelsus is an oral Semaglutide (Garza, 2021).
Sodium-Glucose Cotransporter 2 (SGLT-2) Inhibitors, Canagliflozin (Invokana), and Dapagliflozin (Farxiga) are also listed as causing weight loss due to an increase in glucose excretion through kidneys and urine (Rosenthal and Burchum, 2021, p. 407, table 48.9).
Rosenthal and Burchum (2021) mention specifically two diabetes drug classes that cause weight gain: Second-generation sulfonylureas and meglitinides (glinides), (p.407, table 48.9). I think that all the other oral diabetic drugs are either weight neutral or cause some weight loss.
Q2. Based on the current guidelines of the ADA, it would be appropriate to treat her with monotherapy since the patient is hesitant to take any injections. What agent would you recommend? Please provide the trade name, generic name, the dose you would start the patient with frequency, and route.
Metformin is the first choice of treatment for Diabetes Mellitus Type 2, but ADA now also allows patients to be treated with GLP-1 receptor agonists or SGLT2 inhibitors as first-line treatment for diabetes. Those can be used with Metformin or instead of Metformin (niddk.nih.gov, 2022).
I think that I would choose Metformin for my patient if my patient will agree. Of all three medication classes above, biguanides, Metformin is with the least dangerous side and adverse effects. It may cause lactic acidosis in patients with kidney failure or heart failure, but our patient does not have any kidney or heart issues. GLP-1 receptor agonists can cause pancreatitis, renal insufficiency, and thyroid cancer, while SGLT-2 Inhibitors may cause genital mycotic infections and orthostasis (Rosenthal & Burchum, 2021, p. 407, table 48.9).
I would start managing my patient’s diabetes mellitus 2 with:
Generic Name
Trade Name
Dose with Frequency
Route
Metformin
Glucophage
Immediate release:
Initial dose: 500 mg twice daily. Depending on how Pt is tolerating, one or two weeks later increase to 1000 mg twice daily. Maximum dose is 2,550 mg/day.
Once the patient is tolerating the medication well, it can be switched to extended-release (ER) up to 2,000 mg/day once daily (Lexicomp, 2017, pp. 1460- 1465).
Oral
Q3. What are the contraindications of your selected diabetic therapy?
Contra indications of Metformin: Hypersensitivity to Metformin or any component of the drug formulation, renal function unknown, renal impairment, serum creatinine levels above the upper limits of the normal range, severe renal dysfunction, acute or chronic metabolic acidosis with or without coma, including diabetic ketoacidosis, history of lactic acidosis, severe hepatic dysfunction, cardiovascular collapse, any diseases and conditions associated with hypoxemia such as cardiorespiratory insufficiency, severe dehydration, trauma, infection, post-operative recovery phase, pregnancy, breastfeeding. Metformin needs to stop at least 48 hours before any radiologic procedure that needs a contrast agent (Lexicomp, 2017, pp. 1460-1461).
That means before even starting my patient on Metformin, I have to make sure that I have initial lab work before the medication started with kidney and liver serum values to make sure that the patient has a healthy metabolic system and organs. Monitoring parameters listed in Lexicomp (2017): Urine glucose and ketones, fasting blood glucose, hemoglobin A1C every 6 months or every 3 months, depending on how the patient is doing with their treatment, CBC, renal function every 3 to 6 months, vitamin B12, and folate (p. 1464).
Q4. What lab workup should you obtain? What sort of results will you see in patients who have hypothyroidism and hyperthyroidism?
Thyroid function tests need to be ordered. These include serum thyroid-stimulating hormone (TSH) test, serum thyroxine tests such as total T4, free T4, and serum triiodothyronine tests for total T3, and free T3. For the diagnosis of hypothyroidism usually, TSH levels are needed. If there is hypothyroidism, then the levels of TSH will be high. TSH will also help to diagnose if we are dealing with primary or secondary hypothyroidism. In primary (thyroidal) hypothyroidism TSH levels are high, but in secondary hypothyroidism, TSH levels may low, normal, or slightly elevated. Both T3 and T4 can be monitored for hormone replacement therapy, but T3 will also help to diagnose hyperthyroidism. T3 is very elevated when hyperthyroidism is present (Rosenthal & Burchum, 2021, pp. 417-418).
Q5. What is the treatment of choice for hypothyroidism? What is the mechanism of action? Please provide the initial dose, trade, and generic name of the drug, route, and frequency.
The treatment of choice for hypothyroidism is hormone replacement. The drug of choice for treatment is Levothyroxine (Synthroid) which is synthetic thyroxine, a naturally accruing thyroid hormone, T4 (Rosenthal & Burchum, 2021, p. 419). Levothyroxine works as a hormone replacement or a supplemental therapy for T4. T4 usually serves as a source for T3. Once in the blood, it transforms into T3. T3 penetrates the cell nucleus and binds with nuclear receptors. As a result, it stimulates energy use, stimulates the heart, and promotes growth and development (Roshenthal & Burchum, 2021, p. 416).
Generic Name
Trade Name
Dose and frequency
Route
Levothyroxine
Synthroid
The frequency is once daily.
For subclinical hypothyroidism: Initial 1mcg/kg/day or 25 to 75 mcg daily. Titrate the dose up to 1.5 to 1.7 mcg/kg/day until for Patient-specific full dose is reached every 6 weeks (Lexicomp, 2017, p. 1350).
Oral
Q6. What are the adverse effects and what important teachings will you provide this patient on thyroid replacement therapy?
Since it is a natural hormone, there are no adverse effects are listed in Lexicomp (2017), but it states to monitor heart rate, blood pressure, blood glucose, and be careful with diabetic patients because it may increase blood glucose. If any cardiac symptoms, it is recommended to stop the medication for 7 days, and resume it at a lower dose. I would inform my patient that this therapy is usually a lifelong therapy, and the chosen drug is the same as the natural T4 hormone therefore there will be little to no side effects, but if they feel like their heart beating fast, higher blood pressure, or high blood glucose levels, then inform their healthcare providers for further monitoring and making some changes to the medication dose.
It is important that the patient knows how to take this medication. This medication needs to be taken in the morning with an empty stomach at least 30 to 60 minutes before food. It needs to be taken with a full glass of water (Lexicomp, 2017, p. 1351).
References
Garza, M. (2021). Diabetes Drug Ozempic Approved for Weight Loss. Retrieved from https://diatribe.org/diabetes-drug-ozempic-approved-weight-loss
Lexicomp (2017). Drug Information Handbook for Advanced Practice Nursing (17th ed.). Wolters Kluwer Clinical Drug Information, Inc.
Niddk.nih.gov (2022). The ADA’s 2022 Standards of Medical Care in Diabetes Update. Retrieved from https://www.niddk.nih.gov/health-information/professionals/diabetes-discoveries-practice/ada-2022-standards-of-medical-care-in-diabetes-update
Rosenthal, L.D. and Burchum, J.R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants. Elsevier, Inc.
Seifarth, C., Schehler, B., H J Schneider, H. J. (2012). Effectiveness of metformin on weight loss in non-diabetic individuals with obesity. Exp Clin Endocrinol Diabetes (121/1, pp. 27-31).Retrieved from https://pubmed.ncbi.nlm.nih.gov/23147210/
