Managing Newly Diagnosed Type 2 Diabetes Mellitus in an Obese Patient-Treatment Strategies and Patient Preferences

Managing Newly Diagnosed Type 2 Diabetes Mellitus in an Obese Patient-Treatment Strategies and Patient Preferences

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.

The classes of diabetes medications that are either weight neutral or cause weight loss in diabetic patients include the sodium-dependent glucose cotransporter proteins-2 (SGLT-2) inhibitors, also known as gliflozins, glucagon-like peptide-1 (GLP-1) receptor agonists, and dipeptidyl peptidase 4 (DPP-4) inhibitors. Consistently, GLP-1 has the most impact on weight loss, followed by SGLT-2, while DPP-4 has a neutral weight loss impact on obese patients (Haddad et al., 2023). An example of a medication from the SGLT-2 class is empagliflozin, which is sold under the trade name Jardiance.

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, the frequency, and the route.

Based on the current ADA guidelines, the right agent for monotherapy for the patient since she is hesitant to start on insulin is Metformin. Metformin is the generic name and is sold under the trade name Glucophage. Metformin is recommended as per the ADA guidelines as the first-line medication for managing 2 diabetes (Steinberg & Carlson, 2019).   The patient will be started on Metformin 500mg, which is to be taken twice a day orally. The medication will be taken 30 minutes before the meals. Noting that the diabetic patient is obese, pre-hypertensive, and lab tests show total cholesterol is 260 mg/dL, with triglycerides at 290 mg/dL, HDL at 49 mg/dL, and LDL at 170 mg/dL, Metformin taken 30 minutes before meals is expected to manage both TC and cholesterol levels as has it has been noted to improve postprandial triglycerides and LDL-Cholesterol levels by 8%, and lower plasma glucose by 7.5% compared to if taken during meals (Methnani et al., 2023).

Q3. What are the contraindications of your selected diabetic therapy?

Metformin is contraindicated for renal impairment, leading to high serum creatine levels due to abnormal creatine clearance, congestive heart failure, especially in elderly patients, and acute or chronic metabolic acidosis (Adriana Stoica et al., 2020). Metformin is also contraindicated for reactions and conditions that increase the risk of heart failure, heart attack, and respiratory failure.

Q4. What lab workup should you obtain? What sort of results will you see in patients who have hypothyroidism and hyperthyroidism? 

The confirmation for hypothyroidism will be using Thyroid Stimulating Hormone (TSH) and Free thyroxine test (Free T4 test). TSH test is a blood workup that tests the levels of TSH in the blood. The Free T4 test is a blood workup to test the levels of unbound T4 hormone in the blood. Besides testing for hypothyroidism, these tests can also be used to test for hyperthyroidism. In a patient with hypothyroidism, the results for the TSH test will show elevated levels of TSH, while the test for Free T4 will show low levels of T4 below 0.4 mU/L, indicating reduced thyroid function. For a patient with hyperthyroidism, the results from the TSH test will show low levels of TSH, while the free T4 test will show elevated levels of T4 due to increased thyroid function, increasing production of thyroxine (T4) and triiodothyronine (T3).

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 of choice for hypothyroidism is Levothyroxine (Chiovato et al., 2019). It is mainly marketed under Synthroid, Levoxyl, and Levo T. Levothyroxine works as a synthetic T4 hormone, therefore replacing the low levels of endogenously produced T4 due to reduced thyroid gland function. Once administered, Levothyroxine is activated into triiodothyronine (T3), which is critical in regulating metabolism and production of hormones for growth and development. The initial dose will include levothyroxine 25mcg, which is to be taken orally once daily in the morning.

Q6. What are the adverse effects, and what important teaching will you provide this patient on thyroid replacement therapy?

Thyroid replacement therapy can cause adverse effects, including hyperthyroidism and associated symptoms such as increased heartbeat, heart problems, anxiety, and loss of weight (Kalra et al., 2019). It can also cause osteoporosis. The patient will be educated on the therapy’s risks, medication safety, how to self-administer the therapy, the need for consistent administration of medication, any unexpected symptoms during the therapy, and foods and medications to avoid during the therapy.

 References

Adriana Stoica, R., Simona Ștefan, D., Rizzo, M., Iulia Suceveanu, A., Paul Suceveanu, A., Serafinceanu, C., & Pantea-Stoian, A. (2020). Metformin Indications, Dosage, Adverse Reactions, and Contraindications. In Metformin. https://doi.org/10.5772/intechopen.88675

Chiovato, L., Magri, F., & Carlé, A. (2019). Hypothyroidism in Context: Where We’ve Been and Where We’re Going. Advances in Therapy, 36(2), 47–58. https://doi.org/10.1007/S12325-019-01080-8/TABLES/1

Haddad, F., Dokmak, G., Bader, M., & Karaman, R. (2023). A Comprehensive Review on Weight Loss Associated with Anti-diabetic Medications. Life 2023, Vol. 13, Page 1012, 13(4), 1012. https://doi.org/10.3390/LIFE13041012

Kalra, S., Aggarwal, S., & Khandelwal, D. (2019). Thyroid Dysfunction and Type 2 Diabetes Mellitus: Screening Strategies and Implications for Management. Diabetes Therapy, 10(6), 2035. https://doi.org/10.1007/S13300-019-00700-4

Methnani, J., Hajbelgacem, M., Ach, T., Chaieb, F., Sellami, S., Bouslama, A., Zaouali, M., Omezzine, A., & Bouhlel, E. (2023). Effect of Pre-Meal Metformin With or Without an Acute Exercise Bout on Postprandial Lipemic and Glycemic Responses in Metabolic Syndrome Patients: A Randomized, Open Label, Crossover Study. Journal of Cardiovascular Pharmacology and Therapeutics, 28. https://doi.org/10.1177/10742484231156318/ASSET/IMAGES/LARGE/10.1177_10742484231156318-FIG4.JPEG

Steinberg, J., & Carlson, L. (2019). Type 2 Diabetes Therapies: A STEPS Approach. American Family Physician, 99(4), 237–243. https://www.aafp.org/pubs/afp/issues/2019/0215/

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Discussion Prompt
Post your answers to the 6 questions corresponding to this week’s content on primary care medication management. Provide your responses and rationales. Support your rationales with high-level evidence. (See Post Expectations).
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 were 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.
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, the frequency, and the route.
Q3. What are the contraindications of your selected diabetic therapy?
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?
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.
Q6. What are the adverse effects, and what important teaching will you provide this patient on thyroid replacement therapy?
Expectations
• Length: A minimum of 500 words, not including references
• Citations: At least two high-level scholarly references in APA from within the last 5 years