Week 1
Professor question: Why are statins recommended in the evening instead of
morning? (pg 561)
After starting John on insulin, he calls the office saying he feels bad. He said when he
checked his blood sugar before calling it was 52 mg/dl. What instructions should he be
given?
Answer from classmate: Statins are recommended to be taken in the evening.
Cholesterol synthesis is highest through the night and first thing in the morning. The
biosyntheses of cholesterol follows a normal circadian rhythm. Administration at night
allows for the medication to be at peak levels in the body during the time of high
cholesterol synthesis (Korani et al., 2019).
A blood glucose level <70mg/dL is considered to be hypoglycemia. John called the
office with a sugar of 52mg/dL. He would be given instructions that follow "the rule of
15". This means that when symptoms occur, he should consume 15 g of a fast-acting
carbohydrate. After 15 minutes, he should recheck his blood glucose. John should also
be educated on the best options of carbohydrates to consume. Examples would be 4
oz of juice, four-five hard candies, honey, or half a can of regular soft drink. Another
education point is that John needs to have a meal within a few hours after the low blood
glucose. He may also need to see his doctor for adjustments to be made on insulin
dosage as well as meal patterns to help prevent another low blood glucose episode
from occurring (Woo & Robinson, 2016).
Professor question: What diabetic medications would be contraindicated in patients
with heart failure?
Which diabetic drug(s) may have beneficial effects in heart failure?
(text has info on this but ADA 2020 guidelines has even more up to date info on this
topic, so here is the page. See Recommendation 9.9 and 9.10)
https://care.diabetesjournals.org/content/43/Supplement_1/S98
answer from classmate: Suppose John was showing signs of heart failure. What
diabetic medications would be contraindicated in patients with heart failure?
Metformin is contraindicated in patients with renal insufficiency and unstable heart
failure (Woo & Robinson, 2016). According to the American Diabetes Association
(2020), Metformin can be utilized in patients with stable heart failure, not currently
hospitalized, and Glomerular filtration rate should be greater than 30 ml per hour. In this
instance, John should be switched to fast acting insulin Humalog, to cover mealtimes
, and if his HgbA1C is not sufficiently controlled at the 3 month follow up then, long acting
Lantus insulin should be added to the regime. Additionally, John should be placed on
an Angiotensin Converting Enzyme inhibitor or Angiotensin Receptor Blocker and likely
increase his atorvastatin to 20mg tablet (ADA, 2020).
Which diabetic drug(s) may have beneficial effects in heart failure?
With the scenario presented previously and with the addition of heart failure, John
should be placed on either a sodium-glucose cotransporter 2 inhibitor (SGLTi) or a
glucagon-like peptide 1 receptor agonist (GLP-1 RA) to improve glycemic management
(ADA, 2020a). Both SGLT2i and GLP-1 RA have demonstrated cardiovascular disease
benefits by reducing CVD events and HF hospitalizations in association with diabetes
mellitus (ADA, 2020b). The differential in which medication to use for John would be
based on his Glomerular Filtration Rate (GFR), decreasing GFR rates or worsening
chronic kidney disease would indicate stoppage of SGLT2i and use of GLP-1 RA. Per
the American Diabetes Association (2020), John with mild HF would be initially placed
on a GLP 1- RA Liraglutide (Victoza). Victoza is a once daily injection that aids in
treating T2DM by increasing insulin synthesis and release, decreasing amount of
glucagon and gastric emptying, and reducing food intake (Woo & Robinson, 2016).
Additionally, placing John on a GLP-1 RA would help decrease his obesity with its
proven beneficial tendency to increase metabolism and improve weight loss (Woo &
Robinson, 2016).
Professor question: What lab do we need to check prior to starting metformin? (hint:
which organ function needs to be evaluated?)
What other potential adverse effects are there associated with metformin? (Micromedex
in the library is a good source for this info)
Answer: The most important lab is eGFR/renal function since this determines whether
we can safely use metformin. See recommendations below.
I also included information on contrast administration. The concern is that if dye impairs
renal function, the risk of lactic acidosis is increased.
Another potential adverse effect is B12 deficiency.
"Clinical recommendations based upon the patient’s renal function
• Before initiating therapy, obtain an eGFR
• Initiation of therapy is not recommended in patients with eGFR between 30 –45
mL/minute/1.73 m²
• Obtain an eGFR at least annually in all patients receiving therapy
• In patients at increased risk for development of renal impairment (e.g., the
elderly), renal function should be assessed more frequently
, • If eGFR later falls below 45 mL/minute/1.73 m², assess benefit and risk of
continuing therapy
Iodinated contrast imaging procedures
• Discontinue metformin at the time of or before an iodinated contrast imaging
procedure in patients with an eGFR between 30-60 mL/minute/1.73 m²; in patients with
a history of liver disease, alcoholism, or heart failure; or in patients who will be
administered intra-arterial iodinate contrast
• Reevaluate eGFR 48 hr after the imaging procedure; restart metformin if renal
function is stable"
• https://reference.medscape.com/drug/glucophage-metformin-342717
Professor question: The GLP1RA class drugs end with "-tide". They are highly
recommended as a second agent after metformin by both ADA and AACE/ACE
guidelines.
Per ADA guidelines:
• 9.9 Among patients with type 2 diabetes who have established atherosclerotic
cardiovascular disease or indicators of high risk, established kidney disease, or heart
failure, a sodium–glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor
agonist with demonstrated cardiovascular disease benefit (Table 9.1 (Links to an
external site.), Table 10.3B (Links to an external site.), Table 10.3C (Links to an
external site.)) is recommended as part of the glucose-lowering regimen independent
of A1C and in consideration of patient-specific factors (Figure 9.1 (Links to an external
site.)). A
• 9.10 In patients with type 2 diabetes who need greater glucose lowering than can
be obtained with oral agents, glucagon-like peptide 1 receptor agonists are preferred to
insulin when possible. B
Unfortunately these agents are very expensive, from about $700-1,200/month which will
make them unaffordable for many patients if insurance does not cover the cost. It is
such a shame that cost factors into prescribing!
according to the text, what effect does carbamazepine have on thyroid function tests?
What is the difference b/w total and free T4?
P 1181 Table 41-1
Answer from classmate: According to the text, carbamazepine decreases the serum
concentration of thyroid hormones. It is proposed that carbamazepine increases the
extra-thyroidal metabolism of thyroid hormones (Woo & Robinson, 2016). Total T4
measures the bound and free thyroid hormone and can change when binding proteins
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