EP is a 38-year-old female patient that comes in for diabetes education and
management. She was diagnosed 12 years ago and states lately she is not
able to control her diet although she continues a 1600 calorie diet with
appropriate daily carbohydrate intake (per dietitian prescription) and walks
40 minutes every day of the week. She states compliance with all
medications. She denies any history of hypoglycemia despite being able to
identify signs and symptoms and describe appropriate treatment strategies.
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due to thyroid
cancer
FmHx: Noncontributory
SHx: (−) Smoking, alcohol use, past marijuana use while in high school
Medications: Metformin 850 mg tid, glipizide 20 mg bid, lisinopril 20 mg
daily, sertraline 100 mg daily, multivitamin daily
Vitals: BP 128/82 mg Hg; P 72 beats/min; BMI 31 m/kg2
Laboratory test results: Na 134 mEq/L, K 5.4 mEq/L, Cl 106 mEq/L, BUN -
correct answer--Exenatide - Exenatide (Bydureon) once weekly has been
able to demonstrate weight loss and decrease A1C% by 0.7% to 1.2% in
clinical trials; however it is contraindicated for EP due to the self-reported
history of thyroid cancer.
Dapagliflozin - Dapagliflozin (Farxiga) is contraindicated in this patient due
to hyperkalemia which could be made worse by this drug. The package
insert does not indicate a specific potassium concentration cut off to no
longer use this medication; however, there are better choices in this patient.
Sitagliptin - Sitagliptin (Januvia) is able to obtain an A1C goal of less than
, lOMoAR cPSD| 45211451
7% based on clinical trials and currently the patient does not have any
cautionary objective measures to not use this medication. DPP-IV inhibitors
are weight neutral. DPP-IV inhibitors can be used in patients taking
sulfonylureas; however, it may be recommended to reduce or stop the
sulfonylurea dose.
Acarbose - Acarbose (Precose) is not recommended for initial management
and is associated with significant GI side effects. More information would
be needed regarding fasting and post-prandial numbers. In addition, adding
acarbose would only lower A1c by 0.8% at best and therefore would not
achieve the desired A1C goal of <7%
JR is a 68-year-old African American man with a new diagnosis of T2DM. He
was classified as having prediabetes (at risk for developing diabetes) 5
years before the diagnosis and has a strong family history of type 2
diabetes. JR’s blood pressure was 150/92 mm Hg. His laboratory results
revealed an A1C of 8.1%, normal cholesterol panel, and normal
renal/hepatic function were noted with today’s laboratory test results.
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipidemia
(diagnosed 2 y ago) Pancreatitis (idiopathic) (acute hospitalization 3 y ago)
Family history: Type 2 diabetes
Medication: HCTZ 25 mg daily, simvastatin 10 mg daily
Allergies: SMZ/TMP
Vitals: BP: 150/92 mm Hg P: 78 beats/min RR: 12 rpm Waist Circumference:
46 in Weight: 267 lb Height: 5 ′ 6 ″ BMI: 43.1 kg/m 2
Despite improvements in the past six weeks due to lifestyle changes and
exercise, drug therapy is to be started for JR’s diabet --correct answer-
Metformin is the drug of choice recommended for most patients with
, lOMoAR cPSD| 45211451
diabetes in addition to lifestyle modifications assuming no contraindications
or intolerabilities are present upon evaluation. Metformin has also shown to
provide positive weight neutral/loss effects in obese patients. It is crucial to
know the renal status of patients commencing metformin therapy to limit
the risk of lactic acidosis (JR is without contraindication).
Since his entry A1C is >7.5%, dual therapy is indicated. There are several
potential choices. The second step can be a dipeptidyl peptidase-4 inhibitor,
it can be a glucagon-like peptide-1 (GLP-1) receptor agonist, it can be a TZD,
it can be a sulfonylurea agent, it can be a SGLT2 inhibitor, or it could be
basal insulin. Anything next can be tried depending on what suits the
circumstance
DPP4 inhibitors are weight neutral bet relatively benign side effect profile.
Sitagliptin has been associated with case reports of pancreatitis, so this
specific agent should be avoided. $$$
GLP-1 analog and has data to support an A1C reduction necessary to gain
glycemic control and may assist with weight loss goals for this patient. New
information suggests these agents may provide benefits in those with
ASCVD. JR has a past history of pancreatitis and GLP-1 analogs are not
recommended due to this contraindication
TZDs have data to support an A1C reduction necessary to gain glycemic
control, but are associated with weight gain, negative effects on lipids and
increased risk of fracture. Until recently, TZDs have also been linked to
increased CV events and use has fallen out of favor
Sulfonylureas provide excellent A1C lowering, but are also associated with
weight gain. They also have the potential to cause hypoglycemia, so patient
education is crucial. Because of his allergies to "sulfa", use would be contr
A patient with type 1 diabetes reports taking propranolol for hypertension.
What concern does this information present for the provider? --correct
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