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NR508- Advanced Pharmacology - Week 5, TD
Maria is a 46-year-old woman who presents for her yearly physical examination. Her medical
history is notable for borderline hypertension and moderate obesity. Six months ago her fasting
lipid profile was normal. Maria report that her mother and brother have diabetes and
hypertension. She reports that she knows she should be on a low calorie, low fat diet and
exercising but with her full time job and four children, she finds it difficult to exercise, and she
eats out most of the time. She is 66" tall and weighs 219lbs today, no current medication. She
does report taking a multivitamin, biotin Vit-C when she remembers. She is a nonsmoker, only
drinks sweet tea with each meal, 3-4 cups of coffee per day.
Today: BP 155/95mm Hg, TC 234 mg/dL (H - < 200), LDL 137 mg/dL (H- < 130), HDL 35
mg/dL,(L-55) triglycerides 241mg/dL (H- 35 -135), fasting plasma glucose is 179 mg/dL (H- 70
– 100); HgbA1C is 7.4mg/dL (H- < 5.9). Physical Exam reveals notable for acanthosis nigricans
at the neck but otherwise is normal.
• What are your treatment goals for Maria?
• What is your plan for drug therapy? What is the mechanism of action for each drug?
• Please give five teaching points for each drug prescribed.
• 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.
Hello Dr. McMahon and Class,
What are your treatment goals for Maria?
Maria presents to the clinic for her yearly physical examination. Noting that her history is
positive for borderline hypertension and moderate obesity with fasting lipid profile being normal
6 months ago and a family history of diabetes and hypertension. Maria presents today with
multiple complications that should be assessed and further evaluated. Maria’s BP today is
155/95 mm Hg which is above the normal range, according Armstrong[CAr14], Maria’s BP
should be 140/90 mm Hg. She also presents with high TC (total cholesterol) at 234 mg/dL,
LDL slightly elevated at 137 mg/dL, HDL low at 35 mg/dL, triglycerides high at 241 mg/dL,
fasting plasma glucose is elevated at 179 mg/dL, HgbA1C is elevated at 7.4%. Maria has a BMI
of 36.4% which is considered to be grade 2 overweight[MEd14]. My treatment goals for today’s
visit are to decrease blood glucose level, decrease blood pressure, and discuss other options for
the treatment of hypercholesterolemia. I would also want to check other labs of liver function
and kidney function in preparation of treatment for HTN, diabetes, and possible
hypercholesterolemia.
A thorough examination of Maria would be taken to include possible signs and symptoms within
the past 6 months to help diagnose and corroborate the lab values seen in Maria today.
According to NGSP (2010), with Maria’s HgbA1c, which is an average of her blood glucose
levels over a 3-month period, of 7.4 she has a daily average glucose between 154 and 183. In
https://www.coursehero.com/file/31868635/NR508-Week-5J-TDdocx/
, 2
evaluating a HgbA1c level, anything above 6.5% would be considered Type 2 diabetes and
would need confirmation with a second measurement unless there is a clear indication of
symptoms. The second measurement of Maria’s blood sugar is her fasting plasma glucose of 179
mg/dL today[USD18]. Maria’s lifestyle is evident of what you would probably find in your
everyday person, this day and age. Although it is not a healthy lifestyle to lead, sometimes
things cannot be helped in personal lives, but when it gets to this point, modifications must be
made before serious complications persist. Maria is a mother of four children who has a full-
time job, often finding herself eating out most of the time. Education needs to be provided to
Maria about the risk factors that she is leading up to with her lifestyle choices including
increased morbidity and mortality, diabetes, hypercholesterolemia, hypertension, coronary heart
disease, etc.[MEd14]. Of these listed risk factors, Maria has some of them that need to be
addressed to prevent further complications.
What is your plan for drug therapy? What is the mechanism of action for each drug?
The first thing that I would address is the high blood pressure. Maria has had borderline
hypertension in the past and now has a blood pressure that indicates the need for treatment to
prevent further cardiovascular complications. For the first line treatment of hypertension, in
Maria’s case, I would prescribe an angiotensin converting enzyme inhibitor (ACEI), as these are
recommended for first line treatment for HTN in patients who are diagnosed with diabetes
(James, Ortiz, et al., 2014). The ACE inhibitor that I would choose to start Maria on is lisinopril
10mg one PO (by mouth) daily. The method of action of ACE inhibitors are they block
angiotensin I from converting to angiotensin II, thereby stimulating the release of aldosterone
from the renal glands. The reduced aldosterone causes less water absorption and
sodium/potassium exchange resulting in an increase in potassium. ACE inhibitors also inhibit
bradykinin breakdown by blocking the kininase II enzyme, sometimes leading to a slight dry,
hacky cough[MEd14].
With regards to other treatment for Maria’s other problems this visit, I would start Maria on an
anti-diabetic medication due to her HgbA1C being at 7.4% with a fasting glucose of 179, which
is consisting of 2 different tests that can be used to diagnose Maria with Type 2
diabetes[Ame18]. The first line treatment of choice for Type 2 DM is metformin, as it is safe and
effective in reducing the risk of cardiovascular events, weight, and death. Before prescribing
metformin, I would check Maria’s GFR as metformin is contraindicated in patients with a GFR
of <30 mL/min/1.73 m2 (2018). The mechanism of action of metformin is that it decreases
glucose production and has a minimal effect of insulin sensitivity in the liver and peripheral
tissues. Metformin has also been known to be effective in decreasing triglycerides and low-
density lipoproteins and increasing high-density lipoproteins[MEd14]. Metformin would be
prescribed at the lowest dose possible to see how Maria responds to this medication and how she
is able to tolerate this medication. The medication regimen for treatment of diabetes would be,
metformin 500mg PO (by mouth) twice daily (metformin, 2018).
Regarding the treatment of Maria’s cholesterol issues, at this point in time, education would be
provided about a healthy diet to help decrease Maria’s cholesterol levels. Diet and exercise can
be used in conjunction with treatment of HTN and diabetes to help decrease the cholesterol
https://www.coursehero.com/file/31868635/NR508-Week-5J-TDdocx/
NR508- Advanced Pharmacology - Week 5, TD
Maria is a 46-year-old woman who presents for her yearly physical examination. Her medical
history is notable for borderline hypertension and moderate obesity. Six months ago her fasting
lipid profile was normal. Maria report that her mother and brother have diabetes and
hypertension. She reports that she knows she should be on a low calorie, low fat diet and
exercising but with her full time job and four children, she finds it difficult to exercise, and she
eats out most of the time. She is 66" tall and weighs 219lbs today, no current medication. She
does report taking a multivitamin, biotin Vit-C when she remembers. She is a nonsmoker, only
drinks sweet tea with each meal, 3-4 cups of coffee per day.
Today: BP 155/95mm Hg, TC 234 mg/dL (H - < 200), LDL 137 mg/dL (H- < 130), HDL 35
mg/dL,(L-55) triglycerides 241mg/dL (H- 35 -135), fasting plasma glucose is 179 mg/dL (H- 70
– 100); HgbA1C is 7.4mg/dL (H- < 5.9). Physical Exam reveals notable for acanthosis nigricans
at the neck but otherwise is normal.
• What are your treatment goals for Maria?
• What is your plan for drug therapy? What is the mechanism of action for each drug?
• Please give five teaching points for each drug prescribed.
• 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.
Hello Dr. McMahon and Class,
What are your treatment goals for Maria?
Maria presents to the clinic for her yearly physical examination. Noting that her history is
positive for borderline hypertension and moderate obesity with fasting lipid profile being normal
6 months ago and a family history of diabetes and hypertension. Maria presents today with
multiple complications that should be assessed and further evaluated. Maria’s BP today is
155/95 mm Hg which is above the normal range, according Armstrong[CAr14], Maria’s BP
should be 140/90 mm Hg. She also presents with high TC (total cholesterol) at 234 mg/dL,
LDL slightly elevated at 137 mg/dL, HDL low at 35 mg/dL, triglycerides high at 241 mg/dL,
fasting plasma glucose is elevated at 179 mg/dL, HgbA1C is elevated at 7.4%. Maria has a BMI
of 36.4% which is considered to be grade 2 overweight[MEd14]. My treatment goals for today’s
visit are to decrease blood glucose level, decrease blood pressure, and discuss other options for
the treatment of hypercholesterolemia. I would also want to check other labs of liver function
and kidney function in preparation of treatment for HTN, diabetes, and possible
hypercholesterolemia.
A thorough examination of Maria would be taken to include possible signs and symptoms within
the past 6 months to help diagnose and corroborate the lab values seen in Maria today.
According to NGSP (2010), with Maria’s HgbA1c, which is an average of her blood glucose
levels over a 3-month period, of 7.4 she has a daily average glucose between 154 and 183. In
https://www.coursehero.com/file/31868635/NR508-Week-5J-TDdocx/
, 2
evaluating a HgbA1c level, anything above 6.5% would be considered Type 2 diabetes and
would need confirmation with a second measurement unless there is a clear indication of
symptoms. The second measurement of Maria’s blood sugar is her fasting plasma glucose of 179
mg/dL today[USD18]. Maria’s lifestyle is evident of what you would probably find in your
everyday person, this day and age. Although it is not a healthy lifestyle to lead, sometimes
things cannot be helped in personal lives, but when it gets to this point, modifications must be
made before serious complications persist. Maria is a mother of four children who has a full-
time job, often finding herself eating out most of the time. Education needs to be provided to
Maria about the risk factors that she is leading up to with her lifestyle choices including
increased morbidity and mortality, diabetes, hypercholesterolemia, hypertension, coronary heart
disease, etc.[MEd14]. Of these listed risk factors, Maria has some of them that need to be
addressed to prevent further complications.
What is your plan for drug therapy? What is the mechanism of action for each drug?
The first thing that I would address is the high blood pressure. Maria has had borderline
hypertension in the past and now has a blood pressure that indicates the need for treatment to
prevent further cardiovascular complications. For the first line treatment of hypertension, in
Maria’s case, I would prescribe an angiotensin converting enzyme inhibitor (ACEI), as these are
recommended for first line treatment for HTN in patients who are diagnosed with diabetes
(James, Ortiz, et al., 2014). The ACE inhibitor that I would choose to start Maria on is lisinopril
10mg one PO (by mouth) daily. The method of action of ACE inhibitors are they block
angiotensin I from converting to angiotensin II, thereby stimulating the release of aldosterone
from the renal glands. The reduced aldosterone causes less water absorption and
sodium/potassium exchange resulting in an increase in potassium. ACE inhibitors also inhibit
bradykinin breakdown by blocking the kininase II enzyme, sometimes leading to a slight dry,
hacky cough[MEd14].
With regards to other treatment for Maria’s other problems this visit, I would start Maria on an
anti-diabetic medication due to her HgbA1C being at 7.4% with a fasting glucose of 179, which
is consisting of 2 different tests that can be used to diagnose Maria with Type 2
diabetes[Ame18]. The first line treatment of choice for Type 2 DM is metformin, as it is safe and
effective in reducing the risk of cardiovascular events, weight, and death. Before prescribing
metformin, I would check Maria’s GFR as metformin is contraindicated in patients with a GFR
of <30 mL/min/1.73 m2 (2018). The mechanism of action of metformin is that it decreases
glucose production and has a minimal effect of insulin sensitivity in the liver and peripheral
tissues. Metformin has also been known to be effective in decreasing triglycerides and low-
density lipoproteins and increasing high-density lipoproteins[MEd14]. Metformin would be
prescribed at the lowest dose possible to see how Maria responds to this medication and how she
is able to tolerate this medication. The medication regimen for treatment of diabetes would be,
metformin 500mg PO (by mouth) twice daily (metformin, 2018).
Regarding the treatment of Maria’s cholesterol issues, at this point in time, education would be
provided about a healthy diet to help decrease Maria’s cholesterol levels. Diet and exercise can
be used in conjunction with treatment of HTN and diabetes to help decrease the cholesterol
https://www.coursehero.com/file/31868635/NR508-Week-5J-TDdocx/
