NR 565 Advanced Pharmacology Fundamentals - Week 5ANS Case Study Discussion (2 Versions)

Maria is a 46-year-old woman who presents for her yearly physical examination. Her review of systems is significant for fatigue, constipation and hair loss. Her previous medical history is notable only for obesity. She reports her understanding that she should be on a low calorie, low fat diet with moderate aerobic exercise 4-5 times per week but also notes that having a full-time job and four children makes this difficult to achieve. She has NKDA and takes a multi-vitamin daily. Maria reports a family history of diabetes (mother) and hypertension (brother). She is a nonsmoker. Her diet largely consists of fast food meals. She drinks sweet tea with every meal and an additional 3-4 cups of coffee per day. Previous labs and exam last year are unremarkable. Vitals today: BP 120/70 mm Hg, pulse 76, temperature 98.7, respirations 18, height 5’9”, weight 225 pounds. Urine dip + glucose, fasting plasma glucose 179 mg/dl, HgbA1C is 7.4%, TSH 8.5mU/L and Free T4 0.1 ng/dl. The physical exam is notable for but otherwise is normal. What are your treatment goals for Maria? 1. What is your pharmacologic plan and rationale? (cite with appropriate clinical practice guidelines or scholarly, peer-reviewed journals) 2. What is the mechanism of action for each drug? 3. Please give five teaching points for each drug prescribed. 4. How would you change the plan if her initial HbgA1C was 10.2mg/dL and her fasting blood glucose was 305mg/dL? Provide a detailed alternative plan with the rationale. 1. The patient presents with signs and symptoms of fatigue, constipation, hair loss, TSH 8.5mU/L, and T4 0.1 ng/dl which are all symptoms of hypothyroidism. The plan would be to start the patient on Levothyroxine 50 mcg by mouth once daily before breakfast. The patient should start at this dose and can be increased by 25mcg based on lab test which will be preformed in 4-6 weeks at a follow up appointment. After the target levels of TSH (0.3 to 3.0 mU/L.) and free T4 (9 to 13 μg/dL) are achieved then the patient can have labs monitored every 4-6 months and then annually if the lab results have been within normal limits and steady. It is important the patient takes Levothyroxine on an empty stomach by itself in the morning. The patient also presents with a + glucose in the urine dip, has acanthosis nigricans at the neck, a fasting glucose of 179 mg/dl, and HbgA1C of 7.4% signifies this patient has diabetes type 2 and should be placed on Metformin. Biguanides are considered the initial drug of choice for this patient. This drug has also proven to help the patient lose weight which is an imperative action of the drug. This drug can assist to decrease the HbgA1C by 1.5%-2%. The initial dose of the drug is started low and then slowly titrated to achieve the glycemic control desired. The dose is started at 500mg once or twice daily. This drug has proven to reduce weight, total cholesterol, decrease triglycerides, decrease LDLs, and increase HDLs