Posted: June 11th, 2023

Clinical Management of Type 2 Diabetes NURS 504 – Advanced Pharmacology

NURS 504 – Advanced Pharmacology

CASE STUDY ANALYSIS: DIABETES

Clinical Management of Type 2 Diabetes

Introduction
Type 2 diabetes is a chronic metabolic disorder characterized by elevated blood glucose levels resulting from insulin resistance and progressive β-cell dysfunction. Effective management of type 2 diabetes requires a multifaceted approach that includes lifestyle modifications, pharmacotherapy, and regular monitoring. This case study analysis examines the clinical management of a 70-year-old African American male diagnosed with type 2 diabetes, focusing on risk factor assessment, evaluation of current medications, and recommendations for optimizing treatment outcomes.

Case Presentation
The patient is a 70-year-old African American male presenting for a regular check-up to manage his type 2 diabetes. His blood glucose diary shows levels ranging from 135-200 mg/dL, monitored twice daily before breakfast and dinner. The patient’s medical history includes hypertension for 20 years and type 2 diabetes. Family history is significant for diabetes, hypertension, and coronary artery disease in both parents. Social history reveals no tobacco use for 35 years but alcohol consumption of 10-14 beers per week. The patient does not engage in regular physical activity.

Physical examination findings are unremarkable except for obesity (BMI 35.2 kg/m2) and mild jugular venous distension. Laboratory results show elevated random glucose (290 mg/dL) and glycated hemoglobin (HbA1c) at 8.6%. The patient’s current medications include glyburide 5mg daily, enteric-coated aspirin 325mg daily, and altace 2.5mg daily.

Risk Factor Assessment
Several risk factors contribute to the patient’s suboptimal glycemic control and increased risk for diabetes-related complications. These include advanced age, African American ethnicity, family history of diabetes and cardiovascular disease, comorbid hypertension, obesity, unhealthy diet, physical inactivity, and alcohol consumption (American Diabetes Association, 2021). Addressing these modifiable risk factors through lifestyle interventions and pharmacotherapy is crucial for improving outcomes.

Evaluation of Current Medications
Glyburide, a sulfonylurea, is an appropriate choice for managing type 2 diabetes but appears insufficient in achieving glycemic targets for this patient. Considerations for glyburide use include potential interactions with certain medications, the need for dose adjustment in elderly patients, and the risk of prolonged hypoglycemia (Burchum & Rosenthal, 2019). Given the patient’s elevated HbA1c and random glucose levels, modifications to the diabetes treatment regimen are warranted.

Enteric-coated aspirin is prescribed for the prophylaxis of myocardial infarction due to the patient’s hypertension, age, and family history of cardiac issues. The current dose of 325mg daily may be excessive, and a lower dose of 75-162mg daily is recommended to minimize bleeding risk while maintaining cardiovascular benefits (Burchum & Rosenthal, 2019).

Altace, an angiotensin-converting enzyme inhibitor, is an appropriate treatment for hypertension and the prevention of diabetic nephropathy. The patient’s blood pressure of 145/84 mmHg is slightly above the recommended target of <140/90 mmHg for individuals with diabetes (American Diabetes Association, 2021). Continuing the current dose of altace while monitoring blood pressure response is reasonable. Recommendations To optimize the patient's diabetes management, a comprehensive approach involving both non-pharmacological and pharmacological interventions is recommended: 1. Non-pharmacological therapy: - Adopt a healthy diet with an emphasis on whole grains, lean proteins, fruits, and vegetables - Discontinue alcohol consumption - Engage in regular physical activity, aiming for at least 150 minutes per week of moderate-intensity exercise - Set a weight loss goal of 5% of initial body weight every 3 months until reaching a healthy BMI - Refer to a diabetes nurse educator, nutritional specialist, and podiatrist for comprehensive care - Monitor blood glucose levels at least twice daily and blood pressure daily, keeping a log for follow-up visits - Schedule follow-up appointments every 4-6 weeks to assess response to lifestyle changes and medication adjustments - Provide patient education on signs and symptoms of hypoglycemia, hyperglycemia, and cardiovascular complications 2. Pharmacological therapy: - Discontinue glyburide and initiate metformin as first-line therapy, starting at 500mg twice daily with meals and titrating up to a maximum of 2000mg daily as tolerated and based on glycemic response - If HbA1c target of <7.5% is not achieved after 3 months of metformin monotherapy, consider adding a second agent such as glipizide, starting at 2.5mg daily before breakfast and titrating up to a maximum of 20mg daily based on response - Reduce aspirin dose to 81mg daily to minimize bleeding risk while maintaining cardiovascular benefits - Consider initiating atorvastatin therapy to manage dyslipidemia and reduce cardiovascular risk, starting at 10-20mg daily and titrating based on lipid profile response - Monitor for adverse effects of medications, including gastrointestinal upset, hypoglycemia, and liver function abnormalities, adjusting therapy as needed Conclusion Effective management of type 2 diabetes requires a patient-centered, multidisciplinary approach that addresses both pharmacological and non-pharmacological interventions. By assessing risk factors, evaluating current medications, and providing evidence-based recommendations, healthcare providers can optimize treatment outcomes and reduce the risk of diabetes-related complications. Regular monitoring, patient education, and ongoing communication are essential for successful long-term management of this chronic condition. References: American Diabetes Association. (2021). Standards of Medical Care in Diabetes—2021. Diabetes Care, 44(Supplement 1), S1-S232. https://doi.org/10.2337/dc21-Sint Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's Pharmacology for Nursing Care (10th ed.). Elsevier. Davies, M. J., D'Alessio, D. A., Fradkin, J., Kernan, W. N., Mathieu, C., Mingrone, G., Rossing, P., Tsapas, A., Wexler, D. J., & Buse, J. B. (2018). Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care, 41(12), 2669-2701. https://doi.org/10.2337/dci18-0033 Schwinghammer, T. L., Dipiro, J. T., Ellingrod, V. L., & Dipiro, C. V. (2021). Pharmacotherapy Handbook (11th ed.). McGraw Hill Education. Wexler, D. J. (2020). Initial management of hyperglycemia in adults with type 2 diabetes mellitus. In J. E. Mulder (Ed.), UpToDate. Retrieved April 10, 2023, from https://www.uptodate.com/contents/initial-management-of-hyperglycemia-in-adults-with-type-2-diabetes-mellitus =================== CASE STUDY ANALYSIS: DIABETES NURS 504 - Advanced Pharmacology CASE STUDY ANALYSIS: DIABETES CC: “I’m here for my regular check-up for my diabetes” HPI: CF is a 70-year-old African American male who is visiting his family practice physician for follow-up. His blood glucose diary shows he has been monitoring his glucose levels twice daily (before breakfast and dinner). They range between 135-200mg/dL.PMH: HTN x 20 years, Type II DM.FH: Mother (deceased) with DM and HTN; Father (deceased) with CAD, DM, and HTN; 1 brother (75 yo) who has HTN but otherwise healthy.SH: No tobacco use (cigarettes) for the last 35 years; alcohol use includes 10-14 beers per week at the golf course club house but does not play golf or exercise regularly.All: NKDA.Meds: Glyburide 5mg QDEC ASA 325mg QDAltace 2.5mg QDPE: Gen- A & O, obese elderly African American male.Vitals- BP 145/84, P 80, RR 20, T 98.6, Ht. 5’7”, Wt. 102 kg.Heart- nl S1 and S2, no S3 or S4.HEENT- PERRLA, EOMI, fundi benign, no retinopathy seen.Neck- no bruits, mild JVD, no thyromegaly.Lungs- ClearAbd- +BS, no masses or bruits.MS/Ext- nl ROM, muscle strength 5/5 in UE and LE, no peripheral edema.Neuro- all cranial nerves intactLabs: Na 141 mEq/LK 4.0 mEq/LCl 106 mEq/LCO2 22 mEq/LBUN 20 mg/dLSer 1.0mg/dLGlu 290mg/dLHgb A1c 8.6%2 CASE STUDY ANALYSIS: DIABETESI. AP note A. Present the problem CF, a 70 YO African American male, presents today to his PCP for follow-ups on his glucose readings. He had no other complaints today. He monitors his blood sugars twice daily (morning and night) and they range between 135-200mg/dL. B. Risk FactorsoAgeoAfrican American oFamily History: Mother- DM & HTN; Father- CAD, DM, HTN; Brother- HTNoComorbidities: HTN x 20 yearsoObesity: BMI 35.2oUnhealthy dietoPhysical inactivity and sedentary lifestyleoHistory of cigarette use- quit 35 years agooAlcohol consumption (10-14 beers/week) C. Assessment 1. Evaluation: CF is a 70-year-old African American male who presented to his PCP for follow-up on his Type II DM. He routinely checks his blood glucose (BG) levels twice a day (morning and night) and keeps a BG daily log. His log shows his BG levels range between 135-200mg/dL. According to labs, his BG today is 290mg/dL and his Hgb A1c is 8.6%. Both of these levels are increased above normal range with the normal range of Hgb A1c being <7% and a BG range of <180mg/dL. Due to CF’s current BG and Hgb A1c levels, modification of his current medications is necessary due to his poor management of Type II DM. Riskfactors for CF include age, African American, family history, HTN, obesity, unhealthy diet, physical inactivity and sedentary lifestyle, history of cigarette use, alcohol use, and uncontrolled BG levels. Because CF has many risk factors for developing long-term complications of Type II DM, there will need to be a change to his treatment plan. This new plan will include lifestyle change and changing his current medication regimen. To do this, we also need to do a full cardiac workup due to his mild JVD to include an echocardiogram, chest x-ray, EKG, and cardiac enzymes to rule out cardiac disease which could be secondary to his uncontrolled Type II DM. Home Medications: Glyburide 5mg QD EC ASA 325mg QD Altace 2.5mg QD 3 CASE STUDY ANALYSIS: DIABETES 2. Determine appropriateness of current medications: Glyburide- Appropriate treatment for DM but not controlling CF’s DM(a) Indications: Type II DM indicates the need for non-insulin management; CF needs a second line of treatment such as exercise, healthy diet, and weight losswith the Glyburide to improve his BG levels.(b) Interactions: When taking glyburide, it is important to avoid taking NSAIDS, fluoroquinolones, sulfonamides, broad spectrum antibiotics, MAOIs, type 2 receptor antagonists, and anti-coagulants because these medications can cause hypoglycemia (Burchum & Rosenthal, 2019). Pregnant or lactating women should also avoid glyburide because it can have teratogenic effects. If the patient is taking any kind of beta-blockers with glyburide, they will also need to monitor their BG levels closely as these can cause hypoglycemia. When prescribing glyburide to patients it is important to consider the patients age and mental status (dementia, frequent confusion or forgetfulness) because glyburide can cause prolonged hypoglycemic effects. Also, alcohol consumption should be avoided due to headache, nausea, blurred vision, anxiety, chest pain, and confusion.(c) Drug Dosing: For patients CF’s age, it would be warranted to start with a smaller dose than the average adult due to kidney function and compliance. The average adult dose to start would be 2.5-5mg per day. The elderly should start with 1.25-2.5mg orally once a day with breakfast. Then increase by 2.5mg once compliant or BG levels are not adequate. You can increase the dose once per week. Maximum recommended does is 20mg/day divided into 2times per day (breakfast and dinner) depending on medication tolerance (Burchum & Rosenthal, 2019).(d) Compliance: According to CF, he states he takes his glyburide every day with breakfast, showing he is compliant with his medication regimen. (e) Outcome: According to CF’s BG logs, his HgbA1c, and his random BG level done in the office, it is evident that his BG is not well controlled. Due to CF having an increased BMI, he drinks alcohol daily, and does not exercise, he is considered non-compliant. Glyburide works well for someone who includes a healthy diet and exercises daily, and tries to maintain a healthy weight. Due to this and the fact that CF is older in age, a new hypoglycemic medication should be prescribed. CF also needs to be educated on lifestyle changes such as implementing a healthier diet, decreasing alcohol consumption, and exercising daily. If these changes are implemented, CF should have a decreasein his BMI which will help control his Type II DM. We will also implement a goal for his HgbA1c to be less than 7.5% when he is seen in the office on his next visit. 4 CASE STUDY ANALYSIS: DIABETES(f) Adverse Effect: CF needs to monitor for sustained hypoglycemia, which can be a common side effect for glyburide. If CF does have sustained hypoglycemia, he could have side effects such as thrombocytopenia, aplastic anemia, hepatic failure, leukopenia, cholestatic jaundice, agranulocytosis, and hepatotoxicity (Burchum & Rosenthal, 2019).EC ASA- used in prophylaxis of myocardial infarction (MI) due to CF’s hx of HTN, risk of stroke, and family hx of cardiac issues.(a) Indication: Because CF has HTN, family hx of cardiac issues, his age, and his social history of smoking, as well as being a high risk candidate for stroke r/t Type II DM, EC ASA is prescribed as a prophylaxis for risk of MI. (b) Interactions: Patients who have a history of bleeding, increased ICP, vitamin K deficiency, anti-coagulation therapy, PUD, or active hepatic disease should not take EC ASA. Taking EC ASA while drinking alcohol, on steroids, or NSAIDS, or any anti-inflammatories can increase the risk for formation of a GI ulcer. Medication effectiveness may be increased if taken in combination with methotrexate, Depakote, Coumadin, insulin, or thrombolytics (Burchum & Rosenthal, 2019).(c) Drug Dosing: When taken as prophylaxis for MI/stroke the appropriate dose is50-325mg per day orally. Due to CF’s comorbidities such as Type II DM, his BMI, he is over the age of 40, family hx, and a hx of smoking, the recommended does for him is 75-162mg per day orally (Burchum & Rosenthal, 2019).(d) Compliance: CF reports he takes his EC ASA daily every morning with breakfast.(e) Outcomes: According to the American Association of Clinical Endocrinology (AACE), EC ASA 81mg orally daily is the recommended dose for patients who have Type II DM and are at risk for cardiovascular disease (AACE, 2021). Lowering CF’s does still decreases his risk for development of an MI or stroke and is shown to be just as effective has a higher dose of EC ASA, butalso lowers his risk for bleeding.(f) Adverse Effect: Adverse effects of ASA include GI bleed, leukopenia, hepatitis, hepatic failure, hemolytic anemia, neutropenia, agranulocytosis, seizures, anaphylaxis, and laryngeal edema (Schwinghammer et al., 2021).5 CASE STUDY ANALYSIS: DIABETESAltace- Appropriate treatment for HTN.(a) Indication: CF has HTN, so being on this medication lowers his risk for an MIand also is used as a prevention for diabetic nephropathy. (b) Interactions: Elderly patients should take caution while taking this medication,as well as patients with CHF, COPD, hypovolemia, impaired renal and hepaticfunction, and renal artery stenosis. This medication should not be given to patients who are on renal dialysis, patients on diuretics, or in conjunction withother hypertensives due to the risk of hypotension. If the patient has an increased sensitivity to ACE inhibitors or a history of ACE inhibitors causing angioedema, avoid giving to patients. Patients who are on prazosin, hydralazine, sympathomimetics, potassium-sparing diuretics, vasodilators, or potassium supplements should not take this medication due to its increase in the risk of toxicity (Burchum & Rosenthal, 2019).(c) Drug Dosing: when starting this medication, 2.5mg orally is the daily dose. Patients can go as high as 20mg daily or divided into two separate doses per day (Burchum & Rosenthal, 2019).(d) Compliance: CF explained he takes his Altace in the morning with all of his medications during breakfast.(e) Outcomes: During CF’s office visit, his BP was 145/84 mmHg. With a patient who has Type II DM, the goal for BP is to be <140/90 mmHg. These levels are right about where they should be and because of this we can continue his current medication therapy for his HTN. Will need to make sure the patient understands to check his BP daily before taking his medication and to keep track of his BP’s for the next appointment so they can be monitored.(f) Adverse Effects: Adverse effects of Altace include leukopenia, hepatic failure,thrombocytopenia, anaphylaxis, toxic epidermal necrolysis, pancytopenia, eosinophilia, hepatitis, angioedema, and Steven-Johnson syndrome (Schwinghammer et al., 2021).3. Additional Information Needed:Dietary intakeWeight hxPast HgbA1c levelsHx of hypoglycemic episodesCompliance hxExercise habitsDiabetes education hxAny kind of health disparities such as cultural barriers, access to healthy food options, and financial status6 CASE STUDY ANALYSIS: DIABETESPatients willingness to learn and change habits, goals, and psychosocial statusFasting lipid profile (includes Total LDH, HDL, and Triglycerides)Renal and Liver function tests, Serum Creatinine and GFR, and Urine ketones Cardiac panel, EKG, and chest x-ray4. Desired therapeutic Outcomes:(a) Short Term Goals of Treatment:Prevent hypoglycemia episodesKeep BP controlled at <140/90 mmHgDecrease BG levels to 80-120 mg/dLDecrease HgbA1c to less than 7.5% within the next 3 monthsExercise dailyDecrease BMI within next 3 monthsDecrease alcohol intakeHealthier food choicesCheck BG at least twice per day (morning and night) and record readingsCheck BP daily and record readings(b) Long Term Goals of Treatment:Sustain fasting BG between 80-130 mg/dLKeep BP levels less than 140/90 mmHgHbgA1c level less than 7.0%Total weight loss of >5% of primary body weightStop alcohol consumptionPrevent diabetic complications D. Plan:1. Recommendations:(a) Non-pharmacological Therapy:Make healthier food choicesStop alcohol consumptionExercise at least 3 days per weekWeight loss of at least 5% of initial body weight every 3 months until at desired weightPatient will need referrals to diabetic nurse educator, nutritional specialist, and podiatrist for foot care due to diabetic neuropathy7
CASE STUDY ANALYSIS: DIABETESChecking BG levels at home at least 2 times per day (morning and night)Make a follow-up for 4-6 weeks to re-evaluate medication changes andcheck in on lifestyle changes mentionedRe-check HgbA1c in 3 months Lab work done every 4-6 weeksPatient education on everything discussed in office including new medications, lifestyle changes, and s/s of MI or stroke(b) Pharmacologic Therapy:With the non-pharmacological therapies recommended to CF, over the next 3 months the patient will try to lower his HgbA1c to less than 7.5%. If he is unable to do so, then metformin will be added to his medication daily regimen instead of the glyburide. If, after another 3 months, his HgbA1c goal is still not met, dual medication therapy will be initiated.1) Metformin- oral anti-hyperglycemic8
CASE STUDY ANALYSIS: DIABETESCF will be started on this as a monotherapy at first. If the patient has heart failure or renal insufficiencies the provider should not prescribe this medication. Renal function needs to be checked prior to starting metformin and every few months while on it. Metformin works at its peak when combined with adequate diet and exercise. Oral Dose: 850 mg/day orally with breakfast when just starting; may increase does by 500mg weekly and up to 2550mg/day (Burchum & Rosenthal, 2019).NEW MEDICATION: MetforminE orAEParameter Method Goal Alter Tx When/IfE Lower BG levelSelf-monitoring 2x dayand log to reportLaboratory Results ofHgbA1c Q 3 monthsShort termHgbA1c of<7.5%BG between80-130 mg/dLLong termHgbA1c of7.0%If HgbA1c is notimproved at 3month check,increase dose ofmetformin andmonitor BG levelsAE HypoglycemicReactionsPatient self-reportsPatient monitors BGlevels at homeTo have nohypoglycemiceventsIf pt continues tohavehypoglycemicepisodes, instructto take with mealsto counteractAE Lactic AcidosisPatient self-reportssymptomsLabs- increased LacticlevelNo symptomsof lacticacidosis andnormal labvalues forlactic levelIf patient developss/s of lacticacidosis, send toER for evaluationAE GastrointestinalUpsetPatient self-reportsstomach issuesNo GI upsetsuch as nausea,vomiting,diarrhea,constipation,or abdominalpainIf patient hasthese symptoms,check BG levelsand make apt tobe seen in office2) Glipizide- Oral hypoglycemic medication9 CASE STUDY ANALYSIS: DIABETESIf, after 3 months, CF’s HgbA1c has not reached the therapeutic goal with themonotherapy of metformin, then glipizide will be added to the medication regimen to work in combination with metformin. Glipizide has a shorter half-life than glyburide does and a lower potency, making it the preferred medication of choice for older patients. Patients with hepatic and renal insufficiencies should not take glipizide.Oral Dose: 2.5mg orally daily at least 30 minutes before breakfast. We can increase the dose by 2.5-5mg after at least a week with a maximum of 40mg orally daily (Burchum & Rosenthal, 2019).NEW MEDICATION: Glipizide3) Atorvastatin- anti-lipidemic 10E or AE Parameter Method Goal Alter TxWhen/IfE Lower BG levelsSelf-monitoring 2x day andlog to reportLaboratory Results ofHgbA1c Q 3 monthsShort termHgbA1c of<7.5%BG between 80-130 mg/dLLong termHgbA1c of 7.0%If HgbA1c is notimproved at 3month check,increase BGplasma levelchecksAE GastrointestinalUpsetPt self-reports thisFor the patient tohave no nausea,vomiting,constipation,diarrhea, orabdominal painIf patient hasthese symptoms,check BG levelsand make apt tobe seen in officeAEHypoglycemicReactionsPatient self-reportsPatient monitors BG levelsat homeTo have nohypoglycemiceventsIf pt continues tohavehypoglycemicepisodesAECholestaticJaundicePt self-reports symptomssuch has dark urine,“yellow skin”, light coloredstoolPhysical assessment inofficeLab results- liver panelNo symptoms ofcholestaticjaundice withnormal liverpanel resultsIf patient hassymptoms andincreased liverpanel enzymes,send to ER forfurther workup CASE STUDY ANALYSIS: DIABETESThere is a risk for cardiovascular abnormalities and side effects with type II DM. By taking atorvastatin, CF will decrease his risk for cardiovascular disease by decreasing his lipid levels. Patients with Type II DM over the age of 40 are at an increased risk for cardiovascular disease and should include a statin in their medication regimen to reduce the risk (Schwinghammer et al., 2021).Oral Dose: CF can take 40-80mg per day, will need a lipid panel to decide what dose to start on (Burchum & Rosenthal, 2019).NEW MEDICATION: AtorvastatinE or AE Parameter Method Goal Alter Tx When/IfELowerCholesterol andLDL levelsLab results of lipid panelLDL less than 100Triglycerides less than150HDL greater than 40If LDL level doesnot improve,increase statindoseAEGastrointestinalUpsetPt self-reports GI upsetFor the patient to haveno nausea, vomiting,constipation, diarrhea, orabdominal painIf patient has thesesymptoms, lowerdose of statin orstop completelyand make officeapt.AE Arthralgia Pt self-reports joint pain Pt reports no joint painIf pt still has jointpain lower dose ofstatin or stopcompletely andmake office apt.AELiverDysfunctionLab results of liver panelLab results show normalliver panel- AST, ALT,LFT, BilirubinIf lab values arestill increased,lower dose ofstatin or stopcompletely andmake office apt.AE NasopharyngitisPt reports having fevers,cough, runny nose andnasal congestionPhysical examPt has no cold-likesymptomsPt reports havingcold-likesymptoms, have ptstop medicationand make an officeapt.References11 CASE STUDY ANALYSIS: DIABETESAmerican Association of Clinical Endocrinology (AACE) (2021). AACE Comprehensive Type 2 Diabetes Management Algorithm. Retrieved from https://pro.aace.com/pdfs/diabetes/AACE_2019_Diabetes_Algorithm_03.2021.pdf Burchum, J. R. & Rosenthal, L. D. (2019). Lehne’s Pharmacology for Nursing Care (10th ed.) St. Louis, MO: Elsevier.Schwinghammer, T. L., Dipiro, J. T., Ellingrod, V. L., & Dipiro, C. V. (2021). Pharmacotherapy Handbook (11th ed.) New York, NY: McGraw Hill Education

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