Advanced Pharmacology NSG
533
1. EP is a 38-year-old female patient that comes in for diabetes
education and management. She was diagnosed 12 years ago and
states lately she is not able to control her diet although she
continues a 1600 calorie diet with appropriate daily carbohydrate
intake (per dietitian prescription) and walks 40 minutes every day
of the week. She states compliance with all medications. She
denies any history of hypoglycemia despite being able to identify
signs and symptoms and describe appropriate treatment
strategies.
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due to
thyroid can-cer
FmHx: Noncontributory
SHx: (−) Smoking, alcohol use, past marijuana use while in high
school Medications: Metformin 850 mg tid, glipizide 20 mg bid,
lisinopril 20 mg daily, sertraline 100 mg daily, multivitamin daily
Vitals: BP 128/82 mg Hg; P 72 beats/min; BMI 31 m/kg2
Laboratory test results: Na 134 mEq/L, K 5.4 mEq/L, Cl 106 mEq/L,
BUN 16 mg/dL, SCr 0.89 mg/dL, glucose 128 mg/dL; A1C 7.8%
Based on EP's profile above, which of the agents would be able to
obtain an A1C goal of less than 7% and would be appropriate in the
patient? Please provide an explanation of appropriateness or lack
thereof.: Exenatide - Exenatide (Bydureon) once weekly has been able to demonstrate
weight loss and decrease A1C% by 0.7% to 1.2% in clinical trials; however it is contraindicated for EP
due to the self-reported history of thyroid cancer.
Dapagliflozin - Dapagliflozin (Farxiga) is contraindicated in this patient due to hyperkalemia which
could be made worse by this drug. The package insert does not indicate a specific potassium
concentration cut ott to no longer use this medication; however, there are better choices in this patient.
Sitagliptin - Sitagliptin (Januvia) is able to obtain an A1C goal of less than 7% based on clinical trials
and currently the patient does not have any cautionary objective measures to not use this medication.
DPP-IV inhibitors are weight neutral. DPP-IV inhibitors can be used in patients taking sulfonylureas;
however, it may be recommended to reduce or stop the sulfonylurea dose.
, Advanced Pharmacology NSG
533
Acarbose - Acarbose (Precose) is not recommended for initial management and is associated with
significant GI side ettects. More information would be needed regarding fasting and post-prandial
numbers. In addition, adding acarbose would only lower A1c by 0.8% at best and therefore would not
achieve the desired A1C goal of <7%
, Advanced Pharmacology NSG
533
2. JR is a 68-year-old African American man with a new diagnosis of
T2DM. He was classified as having prediabetes (at risk for
developing diabetes) 5 years before the diagnosis and has a strong
family history of type 2 diabetes. JR's blood pressure was 150/92
mm Hg. His laboratory results revealed an A1C of 8.1%, normal
cholesterol panel, and normal renal/hepatic function were noted
with today's laboratory test results.
Past medical history: Hypertension (diagnosed 4 y ago)
Hyperlipidemia (diag-nosed 2 y ago) Pancreatitis (idiopathic) (acute
hospitalization 3 y ago)
Family history: Type 2 diabetes
Medication: HCTZ 25 mg daily, simvastatin 10
mg daily Allergies: SMZ/TMP
Vitals: BP: 150/92 mm Hg P: 78 beats/min RR: 12 rpm Waist
Circumference: 46 in Weight: 267 lb Height: 5 ′ 6 ″ BMI: 43.1 kg/m 2
Despite improvements in the past six weeks due to lifestyle
changes and exercise, drug therapy is to be started for JR's
diabetes. Which drug therapy would be the best for JR to trial?
Discuss your opinion of JR's lipid management.
Discuss your opinion of JR's blood pressure management.: Metformin is
the drug of choice recommended for most patients with diabetes in addition to lifestyle modifications
assuming no contraindica-tions or intolerabilities are present upon evaluation. Metformin has also shown
to provide positive weight neutral/loss ettects in obese patients. It is crucial to know the renal status of
patients commencing metformin therapy to limit the risk of lactic acidosis (JR is without contraindication).
Since his entry A1C is >7.5%, dual therapy is indicated. There are several potential choices. The second
step can be a dipeptidyl peptidase-4 inhibitor, it can be a glucagon-like peptide-1 (GLP-1) receptor
agonist, it can be a TZD, it can be a sulfonylurea agent, it can be a SGLT2 inhibitor, or it could be
basal insulin. Anything next can be tried depending on what suits the circumstance
DPP4 inhibitors are weight neutral bet relatively benign side ettect profile. Sitagliptin has been
associated with case reports of pancreatitis, so this specific agent should be avoided. $$$
, Advanced Pharmacology NSG
533
GLP-1 analog and has data to support an A1C reduction necessary to gain glycemic control and may
assist with weight loss goals for this patient. New information suggests these agents may provide
benefits in those with ASCVD. JR has
533
1. EP is a 38-year-old female patient that comes in for diabetes
education and management. She was diagnosed 12 years ago and
states lately she is not able to control her diet although she
continues a 1600 calorie diet with appropriate daily carbohydrate
intake (per dietitian prescription) and walks 40 minutes every day
of the week. She states compliance with all medications. She
denies any history of hypoglycemia despite being able to identify
signs and symptoms and describe appropriate treatment
strategies.
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due to
thyroid can-cer
FmHx: Noncontributory
SHx: (−) Smoking, alcohol use, past marijuana use while in high
school Medications: Metformin 850 mg tid, glipizide 20 mg bid,
lisinopril 20 mg daily, sertraline 100 mg daily, multivitamin daily
Vitals: BP 128/82 mg Hg; P 72 beats/min; BMI 31 m/kg2
Laboratory test results: Na 134 mEq/L, K 5.4 mEq/L, Cl 106 mEq/L,
BUN 16 mg/dL, SCr 0.89 mg/dL, glucose 128 mg/dL; A1C 7.8%
Based on EP's profile above, which of the agents would be able to
obtain an A1C goal of less than 7% and would be appropriate in the
patient? Please provide an explanation of appropriateness or lack
thereof.: Exenatide - Exenatide (Bydureon) once weekly has been able to demonstrate
weight loss and decrease A1C% by 0.7% to 1.2% in clinical trials; however it is contraindicated for EP
due to the self-reported history of thyroid cancer.
Dapagliflozin - Dapagliflozin (Farxiga) is contraindicated in this patient due to hyperkalemia which
could be made worse by this drug. The package insert does not indicate a specific potassium
concentration cut ott to no longer use this medication; however, there are better choices in this patient.
Sitagliptin - Sitagliptin (Januvia) is able to obtain an A1C goal of less than 7% based on clinical trials
and currently the patient does not have any cautionary objective measures to not use this medication.
DPP-IV inhibitors are weight neutral. DPP-IV inhibitors can be used in patients taking sulfonylureas;
however, it may be recommended to reduce or stop the sulfonylurea dose.
, Advanced Pharmacology NSG
533
Acarbose - Acarbose (Precose) is not recommended for initial management and is associated with
significant GI side ettects. More information would be needed regarding fasting and post-prandial
numbers. In addition, adding acarbose would only lower A1c by 0.8% at best and therefore would not
achieve the desired A1C goal of <7%
, Advanced Pharmacology NSG
533
2. JR is a 68-year-old African American man with a new diagnosis of
T2DM. He was classified as having prediabetes (at risk for
developing diabetes) 5 years before the diagnosis and has a strong
family history of type 2 diabetes. JR's blood pressure was 150/92
mm Hg. His laboratory results revealed an A1C of 8.1%, normal
cholesterol panel, and normal renal/hepatic function were noted
with today's laboratory test results.
Past medical history: Hypertension (diagnosed 4 y ago)
Hyperlipidemia (diag-nosed 2 y ago) Pancreatitis (idiopathic) (acute
hospitalization 3 y ago)
Family history: Type 2 diabetes
Medication: HCTZ 25 mg daily, simvastatin 10
mg daily Allergies: SMZ/TMP
Vitals: BP: 150/92 mm Hg P: 78 beats/min RR: 12 rpm Waist
Circumference: 46 in Weight: 267 lb Height: 5 ′ 6 ″ BMI: 43.1 kg/m 2
Despite improvements in the past six weeks due to lifestyle
changes and exercise, drug therapy is to be started for JR's
diabetes. Which drug therapy would be the best for JR to trial?
Discuss your opinion of JR's lipid management.
Discuss your opinion of JR's blood pressure management.: Metformin is
the drug of choice recommended for most patients with diabetes in addition to lifestyle modifications
assuming no contraindica-tions or intolerabilities are present upon evaluation. Metformin has also shown
to provide positive weight neutral/loss ettects in obese patients. It is crucial to know the renal status of
patients commencing metformin therapy to limit the risk of lactic acidosis (JR is without contraindication).
Since his entry A1C is >7.5%, dual therapy is indicated. There are several potential choices. The second
step can be a dipeptidyl peptidase-4 inhibitor, it can be a glucagon-like peptide-1 (GLP-1) receptor
agonist, it can be a TZD, it can be a sulfonylurea agent, it can be a SGLT2 inhibitor, or it could be
basal insulin. Anything next can be tried depending on what suits the circumstance
DPP4 inhibitors are weight neutral bet relatively benign side ettect profile. Sitagliptin has been
associated with case reports of pancreatitis, so this specific agent should be avoided. $$$
, Advanced Pharmacology NSG
533
GLP-1 analog and has data to support an A1C reduction necessary to gain glycemic control and may
assist with weight loss goals for this patient. New information suggests these agents may provide
benefits in those with ASCVD. JR has
