NR 565 Week 5 ENDOCRINE CASE STUDY

NR 565 Week 5 ENDOCRINE CASE STUDY Using diagnostic criteria for diabetes, what is John’s diabetic status? What treatment plan should be introduced at this time? According to the Diagnostic Criteria presented by Rosenthal & Burchum (2021, p.398), John is a diabetic and needs to begin initiating lifestyle modifications and pharmacological therapy immediately. The DM Diagnostic Criteria by Rosenthal & Burchum (2021) states that there are four criteria to diagnose Diabetes Mellitus. They include: Fasting plasma glucose ≥126 mg/dL or Random plasma glucose ≥ 200 mg/dL plus symptoms of diabetes or Oral glucose tolerance test (OGTT): 2-h plasma glucose ≥200 mg/dL or Hemoglobin A1c 6.5% or higher. John’s HgbA1C level is 8.1% which surpasses prediabetes and puts him in a disease diagnostic state. Additionally, his plasma glucose level is 200md/dL and he is exhibiting signs and symptoms of diabetes, such as frequent urination during the night. He also endorses weight gain of 3 pounds in the past year. Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes as identified by (American Diabetes Association, 2020). John should be started on Metformin as tolerated. His treatment plan can also include diet, physical activity, and behavioral therapy designed to achieve and maintain weight loss especially with his past medical history of obesity and hyperlipidemia. John should be referred to a dietitian or nutritionist to help assess his nutritional status and create a personalized plan that coordinates with his treatment plan. He should also be encouraged to begin engaging in physical activity weekly. The American Diabetes Association, (2020) recommends in their guidelines that adults with type 2 diabetes should “engage in 150 min or more of moderate- to vigorous-intensity aerobic activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity” (p. 16). 3. Which of John’s behaviors should be addressed to encourage lifestyle changes and decrease A1C levels? - John’s diet consists of mostly fast-food meals. This is a big contributor to his hyperlipidemia and obesity. His cholesterol and A1C levels will be greatly improved if he is able to decrease his fast-food consumption. Fast foods are typically unhealthy and high in fats, sodium, and calories all detrimental to our health and maintaining a healthy weight. John also drinks sweet tea with every meal which is high in sugar and drinks about 3-4 cups of coffee a day. Depending on how he takes his coffee, his coffee drinks are probably also high in sugar and need to be addressed as well. Drinking beers on the weekends is also another behavior that will be addressed. Instead of drinking beers every weekend, he can drink once a month until his A1C is at goal. John’s sedentary lifestyle is also a contributor to his diabetes. The American Diabetes Association (2020) advises that every adult especially those affected by type 2 diabetes, should reduce their daily sedentary behavior and patients should incorporate at least 30 minutes of standing during periods of prolonged sitting to help decrease blood glucose levels. 4. Which behavior in John’s social history poses a potential concern with first line pharmacological treatment for diabetes and why? - The first line treatment for type 2 diabetes is Metformin. In John’s social history it is mentioned he drinks beers on weekends. Drinking alcohol affects decreases vitamin B12 absorption from the gastrointestinal tract. As explained by Rosenthal, L. & Burchum (2021), metformin decreases absorption of vitamin B12 and folic acid and can thereby cause deficiencies of both. Deficiency of B12, can contribute to peripheral neuropathy, a common long-term consequence of diabetes. Additionally, Metformin has a black box warning for lactic acidosis. The metabolism of alcohol and the deficiency of thiamine lead to increase in lactate and can result severe lactic acidosis in patients who have any history of alcohol abuse or chronic use of it. Upon initiating Metformin therapy, John should be educated on signs and symptoms of lactic acidosis which include hyperventilation, myalgia, malaise, and unusual somnolence. Excessive amounts of alcohol increase the risk of lactic acidosis and alcohol use should be limited while on Metformin. 5. Name the specific names of labs you would order and the intervals at which you would order them to monitor the safety and efficacy of metformin. • - While on Metformin laboratory monitoring should include renal and hepatic function studies. The Drugs Information Database (2021) obtaining Glomerular filtration rate (GFR) prior to initiating Metformin. As well as other renal tests including creatinine and BUN. It is recommended to obtain a GFR at least yearly in patients taking Metformin and quarterly for those at risk of renal impairment. It is also recommended to monitor patient’s ALT and AST levels using this same frequency as well. It is advised to measure hematologic (CBC, BMP) parameters on an annual basis and vitamin B-12 as well in patients on Metformin hydrochloride tablets and manage any abnormalities (Drugs Information Database, 2021). Patients should have their A1C levels checked every 3 to 6 months to see how the body is regulating blood sugar levels. Metformin is not notorious for side effects of hypoglycemia, so patients can check their sugar once daily. 6. Atherosclerotic cardiovascular disease (ASCVD) risk factors include age, gender, race, blood pressure, cholesterol values, history of diabetes, tobacco use, treatment of hypertension, statin therapy, and aspirin therapy. Look at Alfonson’s ASCVD risk factors. Should Alfonso be taking something for hyperlipidemia? If so, what would you recommend? - Alfonso should certainly be taking something for hyperlipidemia, according to the ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease (2020), he should be started on high-intensity statin therapy since he is an adult 40-70 years of age and falls into Class IIa. His family history, history of hypertension, his cholesterol values, his presentation on blurry vision which could be indicative of an onset of diabetes type 2, all put him at a great risk for Atherosclerotic cardiovascular disease (ASCVD). I would recommend starting him on Atorvastatin (Lipitor), 40mg daily, this daily dosage lowers LDL-C by approximately ≥ 50% on average. Alfonso should also be started