Expectations Length: A minimum of 180 words, not including references Relate/com

Expectations
Length: A minimum of 180 words, not including references
Relate/compare to another study/article
Citations: At least two high-level scholarly references in APA from within the last 5 years
An obese patient, age 45, comes to your office. She recently moved from another state three weeks ago and told you that her FNP diagnosed her with type 2 diabetes mellitus. She is currently not on any medicine for her diabetes, and she wishes to avoid insulin, if possible. She is a non-smoker. Her blood pressure is 138/74 mmHg. Labs from 3-weeks ago was hemoglobin A1C = 8.4%; total cholesterol = 260 mg/dL, triglycerides = 290 mg/dL, HDL = 49 mg/dL, LDL = 170 mg/dL (calculated 10-year ASCVD risk = 6.2%). You discuss current treatment goal recommendations endorsed by the ADA regarding glycemic control, blood pressure control, and lipid management. She agrees to start any medications you recommend with lifestyle modification and a DASH diet to treat hypertension.
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.
Rosenthal and Burchum (2018) share that for the treatment of diabetes mellitus, biguanides can be used to lower blood glucose and improve glucose tolerance. Glucophage or metformin is a biguanide that is weight neutral. In fact, patients taking metformin may actually lose weight while on the therapy. Apovian, et al. identifies multiple antihyperglycemic medications that can be categorized as weight neutral or promote weight loss such as α-glucosidase inhibitors, GLP-1 receptor agonists, Amylin mimetics, SGLT2 inhibitors, and DDP-4 inhibitors (2018).
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.
As this patient requests to avoid injections and is willing to modify both physical activity and diet, I believe, utilizing the ADA Pharmacotherapy recommendations, that metformin would be the best medication on which to start this patient. According to Stoica, et al. (2020) patients are usually started on 500mg daily and increased 500mg weekly until proper dosing is met. Daily dosing should not exceed 2550 mg daily. According to the ADA (2022), metformin is an oral medication that has a high rate of efficacy, is weight neutral or can help to lose weight, is neutral regarding the progression of both heart failure and kidney disease, and is relatively low cost. The other oral medications are either associated with weight gain or are relatively high cost.
Glucophagemetformin500mg daily to startOral
Q3. What are the contraindications of your selected diabetic therapy?
The ADA (2022) shares that metformin is contraindicated in patients with eGFR less than 30.
The patient returns to your office six months later, complaining of fatigue for the past two months, constipation, and heavy, irregular menses. Upon examination, you note that her skin is dry, and her fingernails are brittle. You suspect she has hypothyroidism.
Q4. What lab workup should you obtain? What sort of results will you see in patients who have hypothyroidism and hyperthyroidism?
Adult hypothyroidism is a result of reduced T3 and T4 which promote excess release of TSH or from insufficient secretion of TSH and TRH. Hyperthyroidism is often caused by thyroid stimulating immunoglobulins produced by an autoimmune disease which result in excessive secretion of thyroid hormone (Rosenthal & Burchum, 2018). In the case of hypothyroidism, lab results will show increased TSH and decreased T3 and T4 in the serum. With hyperthyroid, the opposite is true, with TSH levels low and T3 T4 levels increased.
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 for hypothyroidism is lifelong replacement of T4 with levothyroxine (Levothroid, Synthroid). Much of the T4 is metabolized into T3, mimicking normal levels of these naturally occurring hormones. Rosenthal and Burchum (2018) share a full replacement dose for an adult ranges from 100-125 mcg daily, usually taken once on an empty stomach approximately 30 minutes before food. Typically, this medication is weight based dosing of 1.7mcg/kg/day (Rosenthal & Burchum, 2018).
Synthroidlevothyroxine100-125mcg/daily to startoral
Q6. What are the adverse effects, and what important teaching will you provide this patient on thyroid replacement therapy?
Rosenthal and Burchum (2018) explain that levothyroxine is a synthetic preparation of the same hormone found in the body, thus those with hypothyroidism will most likely need to take this replacement therapy for life. The absorption of this medication is reduced by food, so it is important to take the medication on an empty stomach. Since the hormone is a regulatory hormone, it is preferable to take it at the same time everyday to keep hormone levels steady. It takes about a month to see the full effects of the medication. When taken properly, side effects are rare, however, thyrotoxicosis is a possibility with acute overdose. In this case, the patient would experience symptoms including nervousness, insomnia, heat intolerance and sweating, and tachycardia (Rosenthal & Burchum, 2018).
ADA’s standards of care in diabetes—2023 abridged for Primary Care Providers. (2022). Clinical Diabetes, 41(1), 4–31. https://doi.org/10.2337/cd23-as01
Apovian, C. M., Okemah, J., & O’Neil, P. M. (2018). Body weight considerations in the management of type 2 diabetes. Advances in Therapy, 36(1), 44–58. https://doi.org/10.1007/s12325-018-0824-8
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. Elsevier.
Stoica, R. A., Ștefan, D. S., Rizzo, M., Suceveanu, A. I., Suceveanu, A. P., Serafinceanu, C., & Pantea-Stoian, A. (2020). Metformin indications, dosage, adverse reactions, and contraindications. Metformin. https://doi.org/10.5772/intechopen.88675