Please Reply To The Following 2 Discussion Posts
Please Reply to the following 2 Discussion posts:
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DISCUSSION POST # 1 Reply to Elaine
The patient in this case study has an elevated A1C, elevated lipid levels, and a moderate risk for cardiovascular disease. Based on the American Diabetes Association (ADA) guidelines this patient should be started on metformin and lifestyle modifications including diet and physical activity plans which also fit the patient’s request not to be on insulin (ADA, 2022; Brock, 2020). Metformin remains the mainstay for initial diabetes management and is also useful for weight loss. Metformin is a biguanide, brand names include Glucophage and Fortamet, and works by increasing insulin receptor sensitivity in target tissues of skeletal muscles and adipose cells, reducing glucose absorption from the GI tract, and inhibiting glucose production in the liver (Rosenthal & Burchum, 2021). For this patient, I recommend starting with oral Glucophage XR 500mg once daily at night with meals. The medication is generally well tolerated with mild complaints of gastrointestinal upset, with rare cases of lactic acidosis reported.
Contraindications for metformin include IV contrast since they are both excreted by the kidneys and can result in an increased risk for lactic acidosis (Rosenthal and Burchum, 2021). Ideally, the patient should stop taking metformin 48 hours prior to the use of IV contrast for radiological procedures and drink plenty of water. A patient that is also taking levothyroxine may need to have their metformin dose increased since levothyroxine will inhibit metformin uptake.
Some other weight-neutral medication classes for diabetes include dipeptidyl peptidase-4 inhibitors, alpha-glucosidase inhibitors, and bromocriptine-QR (ADA, 2022; Brock, 2020). Some weight loss diabetic medications include metformin as we discussed, glucagon-like peptide-1 receptor antagonist, sodium-glucose cotransporter 2 inhibitors, and pramliontide. Jenuvia, generic name sitagliptin, is an example of a dipeptidyl peptidase-4 inhibitor (Rosenthal & Burchum, 2021).
Due to the patient’s symptoms and complaints at the six-month follow-up visit, I would recommend the initial lab of the following: complete metabolic panel, complete blood count, thyroid panel, hemoglobin A1C, and vitamin B-12 levels. Metformin can cause a decrease in vitamin B12 levels which can cause some of these symptoms including fatigue (Rosenthal & Birchum, 2021; Ankar & Kumar, 2022).
According to Hennessey & Esplaillant (2018), the guidelines still recommend monotherapy for treatment of hypothyroid patients. The standard treatment is thyroid hormone replacement using levothyroxine, brand name Synthroid (Chiovato et al., 2019; Rosenthal & Burchum, 2021). The initial starting dose for adults is recommended under the age of 50 years is 1.6 mcg/kg per day orally (Chiovato et al., 2019).
Levothyroxine should be taken in the morning on an empty stomach 1 hour prior to meals (Rosenthal & Burchum, 2021). Levothyroxine is generally well tolerated however in rare situations it can lead to thyrotoxicosis which can lead to serious complications such as hypertension, tachycardia, hyperthermia, tremors, acute psychosis, and myocardial infarctions (Nguyen & Jialal, 2022). Additionally, chronic overuse of levothyroxine can increase the incidence of bone loss and atrial fibrillation (Rosenthal & Burchum, 2021).
Drugs that reduce the absorption of levothyroxine include minerals like magnesium salts, calcium supplements, aluminum-containing medications, and iron supplements (Rosenthal & Burchum, 2021). The following medications may also reduce the absorption of levothyroxine including histamine 2 receptor blockers, proton pump inhibitors, sucralfate, cholestyramine, orlistat, furosemide, and colestipol (Eghtedari & Correa, 2022; Rosenthal & Burchum, 2021). As a result of the decreased absorption caused by these medications, levothyroxine should be given at least four hours before administering these supplements or medications.
Levothyroxine can affect the metabolism or uptake of several drugs including phenytoin, carbamazepine, rifampin, sertraline, and phenobarbital, warfarin, metformin, insulin, and digoxin so these drug dosages may need to be increased or decreased accordingly (Rosenthal & Burchum, 2021).
DISCUSSION POST # 2 Reply to Astrid
There are different classes of drugs for the treatment of type 2 diabetes mellitus (T2DM) that work in different ways to lower blood glucose levels and have the added benefit of weight loss, while others are considered weight neutral. For instance, the DM medications Byetta (exenatide) and Invokana (canagliflozin) cause weight loss and belong to the drug classes glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium-glucose co-transporter 2 inhibitors (SGLT- 2i), respectively (Apovian et al., 2019). Some sources state that Glucophage (metformin), which belongs to a drug class called biguanide, causes weight loss, while others state that it is a weight-neutral drug (Apovian et al., 2019; Rosenthal & Burchum, 2021). Januvia (sitagliptin) is a dipeptidyl peptidase-4 (DPP4) inhibitor that is weight neutral.
Based on the current guidelines of the American Diabetes Association (ADA) (2022), it would be appropriate to treat the patient with monotherapy since she is hesitant to take any injections. The first-line therapy in treating and managing T2DM includes metformin and comprehensive lifestyle changes (i.e., heart-healthy diet, increased physical activity, weight loss, glycemic and blood pressure control, and lipid management). Metformin, which falls under various brand names of Glucophage, Glucophage ER, Fortamet, Glumetza, and Riomet, lowers blood glucose levels and tolerance by insulin receptors in target tissues, such as fat and skeletal muscle, resulting in increased glucose uptake in response to whatever insulin is available (Rosenthal & Burchum, 2021). The initial recommended dose of metformin is 500 mg by mouth once a day, Wexler (2022) recommends taking metformin in the evening with or after dinner to reduce the chance of getting side effects, such as nausea, diarrhea, and decreased appetite.
Furthermore, metformin and other biguanides are contraindicated in many individuals with chronic kidney disease (glomerular filtration rate < 30 ml/min), cirrhosis, congestive heart failure, and respiratory insufficiency associated with hypoxemia (Stoica et al., 2019). Biguanides impede mitochondrial oxidation of lactic acid, which can cause lactic acidosis. Metformin has a black box warning for lactic acidosis, where too much lactic acid builds up in the blood and cannot be eliminated easily, resulting in metabolic acidosis. Individuals should be aware of early signs of lactic acidosis, such as hyperventilation, respiratory distress, malaise, and myalgia (Rosenthal & Burchum, 2021).
Moreover, the patient must always start with lifestyle changes before starting her on medications for hypertension (HTN) and dyslipidemia. To confirm the diagnosis of HTN, the patient must have a BP ≥ 130/80 on two occasions (Rosenthal & Burchum, 2021). Antihypertensive must be initiated when the target BP goal is not achieved with lifestyle modifications. However, according to the American College of Cardiology/American Heart Association (ACC/AHA), the patient has stage I hypertension (138/74) with a calculated 10-year ASCVD risk of 6.2%. Patients with T2DM should achieve a target BP of < 130/88 (Joseph et al., 2022). Initiating an angiotensin-converting enzyme inhibitor (ACEI), which is the preferred therapy for managing co-existing DM and HTN, may slow the progression to cardiovascular mortality (Joseph et al., 2022). ACC also recommends moderate-intensity statin therapy in adults 40-75 years of age with DM regardless of estimated 10-year ASCVD risk. Therefore, the patient can be started on Lisinopril 10 mg by mouth once a day for HTN and Atorvastatin 10 mg by mouth once a day at bedtime for lipid management.
During the six months follow-up, the patient complains of fatigue, constipation, heavy and irregular menses, dry skin, and brittle fingernails, some of the clinical manifestations of hypothyroidism. To confirm this diagnosis and evaluate her thyroid function, a thyroid function test that includes serum thyroid-stimulating hormone test (TSH), T3 (triiodothyronine), and T4 (thyroxine) should be performed. Since the anterior pituitary is extremely sensitive to changes in thyroid hormone levels, measuring serum TSH is the most sensitive approach for detecting hypothyroidism (Rosenthal & Burchum, 2021). This means that even a slight drop in serum T3 and T4 can result in an extreme increase in serum TSH. Therefore, an excessively high TSH level is indicative of hypothyroidism, even at a mild level. For instance, elevated TSH, low T3, and low T4 levels indicate hypothyroidism. Conversely, a low TSH level with elevated T3 and T4 levels indicates hyperthyroidism.
The treatment of choice for hypothyroidism is thyroid hormone replacement therapy (Ross, 2022). The standard replacement therapy is the generic drug levothyroxine; trade names include Levoxyl, Synthroid, Levothroid, Tirosint, Euthyrox, and Unithroid. Levothyroxine is a synthetic version of the body’s endogenous thyroid hormone: thyroxine (T4). Levothyroxine is converted to its active metabolite T3 in peripheral tissues, binding to thyroid receptor proteins within the nucleus (Eghtedari & Correa, 2022). Once inside the nucleus, thyroid hormones stimulate energy and the heart, promote growth and development, and influence gene transcription, causing protein synthesis. The recommended initial dose is 1.6 mcg/kg/day with a 12.5 to 25 mcg/day dose adjustment every six to eight weeks as needed. The patient must take one tablet of the initial dose prescribed by mouth once a day, on an empty stomach, preferably in the morning.
According to Rosenthal & Burchum (2021), levothyroxine rarely causes adverse effects when administered in appropriate dosage. However, when taken more than what is prescribed, thyrotoxicosis may result. The patient must be informed about the signs and symptoms of thyrotoxicosis (tachycardia, nervousness, hyperthermia, heat intolerance, angina, diaphoresis, and tremors) and instructed to notify the prescriber as soon as possible. Other overdose-associated symptoms are increased risk for atrial fibrillation and accelerated bone loss.
In addition, it is vital to provide the patient with education about the importance, risks, and benefits of this life-long hormone replacement therapy. The patient must be instructed to take the drug on an empty stomach in the morning, at least 30 to 60 minutes before breakfast because food reduces the absorption of oral levothyroxine, and to monitor TSH six weeks after initiating therapy. Lab tests should indicate normal plasma levels of TSH and T4. Once TSH has been stabilized, monitoring and measuring TSH levels at least once a year is essential. Additional education about this medication includes drug interactions with products containing iron, calcium, magnesium, iron, and aluminum, histamine-2 receptor blockers, and proton pump inhibitors. Therefore, the patient must be cautious with over-the-counter drugs that can reduce the absorption of levothyroxine.