Response – Glycemic and Diabetes Management

Response – Glycemic and Diabetes Management

Responding to Hamid 

Hello Hamid,

Thank you for the informative post on the approach to glycemic management. Increasing the metformin dose while contemplating the use of other drugs reflects the general clinical interests related to the matter. It is essential to consider and acknowledge the pros and cons of each such treatment and their potential dangers, especially if the patient is elderly and has other ailments. Regarding the escalation of the dose of metformin, including lifestyle changes plays a vital role in achieving the target A1C rate, according to Christofides (2019). Culturally tailored interventions to improve diet and increase physical activity can decrease insulin resistance and A1C levels. Also, considering a shift to extended-release metformin is a strategic move that may enhance tolerability and adherence.

Notably, the recommendation to initiate a sulfonylurea-like glipizide is cheap and, therefore, acceptable by current guidelines. While hypoglycemia is less probable in young adults, it is a potential risk in older adults and should be closely monitored. Thus, it is reasonable to consider a DPP-4 inhibitor as an alternative because it has a low risk of hypoglycemic events and good tolerability, according to Makrilakis (2019). However, this approach is more costly and offers the right balance between effectiveness and safety for patients with limited resources.

It is pleasing to see that GLP-1 receptor agonists are recommended for their advantages in weight loss and cardiovascular risk reduction (Cornell, 2020). However, the price has remained high, although the side effects on the stomach can also be severe, so anyone on a limited Budget must consider this carefully. It is agreed that patient assistance programs, as mentioned above, must be investigated to ensure this therapy is possible.

To sum up, the treatment plans listed and the appropriate inclusion of cultural and financial factors provide an exhaustive approach to assessing this patient’s requirements. The sources discussed above may be used to provide tangible aid in effectively managing the conditions listed, thereby underlining the value of a patient-centered approach to chronic disease management.

References

Christofides, E. A. (2019). Practical Insights Into Improving Adherence to Metformin Therapy in Patients With Type 2 Diabetes. Clinical Diabetes, 37(3), 234–241. https://doi.org/10.2337/cd18-0063

Cornell, S. (2020). A review of GLP‐1 receptor agonists in type 2 diabetes: A focus on the mechanism of action of once‐weekly agents. Journal of Clinical Pharmacy and Therapeutics, 45(S1), 17–27. https://doi.org/10.1111/jcpt.13230

Makrilakis, K. (2019). The Role of DPP-4 Inhibitors in the Treatment Algorithm of Type 2 Diabetes Mellitus: When to Select, What to Expect. International Journal of Environmental Research and Public Health, 16(15), 2720. https://doi.org/10.3390/ijerph16152720

Responding to Krizelle’s post

Hello Krizelle,

Thank you for the elaborate discussion on the patient’s treatment plan. When developing a new care plan, it is important to consider the patient’s financial status and the prevailing language barriers consequential to the treatment. A full understanding of the treatment options and the implications of each is the first stepping stone to adherence and better health.

It is reasonable to continue the current medication regime to manage hypertension and hyperlipidemia. However, as noted above, current diabetes management needs modification, especially concerning the A1C level of 7.8%. The recommendation of the GLP-1 RA or SGLT2i medication is grounded on the available literature, especially about patients with moderate to high cardiovascular risk, as discussed by Rolek et al. (2023). While controlling for BMI and age, these drugs have highly relevant advantages, Including weight loss and cardiovascular protection.

Consequently, some drawbacks remain to GLP-1 RAs and SGLT2is, including the relatively high cost of the medication. Thus, it is crucial to talk in detail about these costs, including the insurance and the patient’s support program. According to Lin et al. (2021), it only becomes logical to opt for DPP-4 inhibitors as these drugs are relatively cheaper while still possessing a meaningful impact on A1C levels. These do not necessarily reduce the risk of cardiovascular disease as much, but they are affordable and come with a lower risk.

It is very beneficial to focus on resources such as Affordable Diabetic, ADA Co-Pay Relief Program, and NeedyMeds. These programs help lessen the expenses incurred, thus making it easier to adhere strictly to the programs in question. Educating about these options is important to ensure the availability of any necessary medications and supplies while maintaining financial stability, as stated by Gunter et al. (2023).

Thus, the final approach proposed in this response is comprehensive and considers medical angles while also focusing on equipment functionality. Choosing additional diabetes medications to evaluate efficacy, safety, and cost in treating or managing diabetes is patient-centered care. This approach takes care of daily clinical requirements while also considering the overall sustainability of a treatment regime.

References

Gunter, K. E., Tanumihardjo, J. P., O’Neal, Y., Peek, M. E., & Chin, M. H. (2023). Integrated Interventions to Bridge Medical and Social Care for People Living with Diabetes. Journal of General Internal Medicine, 38(S1), 4–10. https://doi.org/10.1007/s11606-022-07926-2

Lin, W.-Q., Cai, Z., Chen, T., Liu, M.-B., Li, N., & Zheng, B. (2021). Cost-Effectiveness of Dipeptidylpeptidase-4 Inhibitors Added to Metformin in Patients With Type 2 Diabetes in China. Frontiers in Endocrinology, 12(3). https://doi.org/10.3389/fendo.2021.684960

Rolek, B., Haber, M., Gajewska, M., Rogula, S., Pietrasik, A., & Gąsecka, A. (2023). SGLT2 Inhibitors vs. GLP-1 Agonists to Treat the Heart, the Kidneys and the Brain. Journal of Cardiovascular Development and Disease, 10(8), 322. https://doi.org/10.3390/jcdd10080322

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PEER RESPONSE 1:

Hamid Ahmad posted Aug 27, 2024 2:47 PM

Improving glycemic control is of the utmost importance to this 64-year-old woman with hypertension, hyperlipidemia, type 2 diabetes (T2DM), and financial limitations as well as low English skills. She needs to optimize her diabetes therapy because her A1C is 7.8% and her hypertension and cholesterol are well-managed. Her diabetes treatment still revolves around metformin; however, we might consider adding a second agent due to her inadequate glycemic control and BMI of 32 kg/m². Based on clinical recommendations and her individual circumstances we have three potential courses of action.

Frist Option: Intensifying Metformin Therapy

According to the guidelines, the patient is currently taking the highest recommended dose of metformin, which is 2000 mg/day. However, we have a few options that can improve metformin treatment without increasing the dosage, as this would not provide any extra glycemic control. One option is lifestyle modification, like changing her diet and increasing her exercise habits to reduce insulin resistance and improve glycemic control (ElSayed et al., 2023). We should discuss a personalized, culturally specific dietary recommendation with the patient. Due to her limited proficiency in English, we can use translation services to appropriately communicate dietary education with this patient. Moreover, changing to an extended-release metformin may enhance her A1C levels (ElSayed et al., 2023).

If modifying patient’s lifestyle does not produce satisfactory results, it may be helpful to consider adding a cost-effective secondary medication, such as a sulfonylurea like glipizide, in combination with metformin. It is a low-cost medicine but comes with greater risk of hypoglycemia, therefore, it is important to consider the potential risk of hypoglycemia, especially in the elderly patients. Consider exploring a potential supplement option like a DPP-4 inhibitor. It is known for its favorable tolerance levels and minimal risk of hypoglycemia. However, it’s important to be mindful of the potential cost implications that may pose a limitation (Buse et al., 2019).

Treatment Option 2: Adding a GLP-1 RA

Another option is to add a GLP-1 receptor agonist, such as liraglutide or semaglutide. These medications are effective for managing blood sugar, promoting weight loss, and reducing the chances of heart disease. These factors are crucial for her as she is both overweight (BMI of 32 kg/m²) and elderly (ElSayed et al., 2023). If the patient has a fear of needles or struggles to follow instructions, receiving injections of GLP-1 receptor agonists may pose an issue. Moreover, these medications come with a high cost, and these individual faces significant challenges in affording them as she relies on her deceased husband’s disability payments and a modest retirement fund. Expenses could potentially decrease through patient assistance initiatives, but additional investigation is necessary. Moreover, individuals may be less inclined to continue with something if they experience common stomach issues such as nausea and vomiting, especially if these symptoms are not accurately explained in a way that aligns with their cultural beliefs (Buse et al., 2019).

Treatment Option 3: Adding SGLT2- I

The third choice is to include an SGLT2 inhibitor such dapagliflozin or empagliflozin. For patients with diabetes, hypertension, and cardiovascular risk factors such as this one, these drugs offer renal and cardiovascular protection in addition to improving glycemic control and promoting weight loss (Zinman et al., 2015). Compared to injectables like GLP-1 receptor agonists, the oral form of SGLT2 inhibitors may be more palatable. Despite the availability of aid programs, money may still be a concern. Another consideration when giving this medicine should be the increased risk of genitourinary infections, particularly in elderly women (ElSayed et al., 2023).

Financial and Cultural consideration

For this patient, it is important to address both culture and financial issues to make sure they adhere with their treatment. Since she doesn’t speak English very well and needs her son to translate, it’s important to teach her about her disease and medications in her own language. Having interpreters or training materials translated can help her understand how to take care of her diabetes better and give her more confidence. Cost is also a big part of figuring out the best way to treat someone. For long-term success, it is important to make sure that any extra treatments or medications are affordable or can be helped by patient aid programs.

Local Resources 

As a healthcare provider in Stockton, California, I’m aware of several programs that can help patients access affordable diabetes care and medications. These resources extend beyond the city limits. In less than a year, when this patient turns 65, she’ll be eligible to apply for Medicare, which should significantly reduce her medication costs. Here are some additional resources we can offer her:

1. San Joaquin General Hospital’s Diabetes Education Program: This program offers diabetes education, nutrition counseling, and medication management at reduced or no cost to low-income patients. It can be an invaluable resource for patients needing diabetes management support. https://www.sanjoaquingeneral.org/community-outreach
2. St. Mary’s Dining Room Free Clinic: This clinic offers free medical services, including diabetes care, to underserved populations in Stockton. They also provide support in accessing prescription assistance programs, which can help with the cost of medications. More details can be found on their website: St. Mary’s Dining Room Free Clinic. https://www.findhelp.org/st.-marys-dining-room–stockton-ca–medical-clinic-/5756930340945920?postal=95201
3. GoodRx: This service is very popular and allows patients to find discounted prices for medications at local pharmacies. It is an excellent resource for obtaining affordable medications, including metformin and other diabetes medications. https://www.goodrx.com
4. RxAssist: Offers information about patient assistance programs to help low-income patients access free or low-cost medications. This service could help the patient obtain the medications she needs. More information can be found at https://www.rxassist.org/
5. CostPlusDrugs: This online pharmacy offers a variety of medications at wholesale prices, including many diabetes-related drugs. It is a low-cost option for patients concerned about affordability. Learn more at https://costplusdrugs.com/
6. NeedyMeds is a national resource that provides information on patient assistance programs and drug discount programs. It can help patients find low-cost medications, including diabetes supplies. For more details vist https://www.needymeds.org

 

PEER RESPONSE 2:

BY: KRIZELLE

Week 5 Discussion

Prior to initiating a plan of care for this patient, certain considerations should be made based on the patient’s financial situation and the language and cultural barriers. If the patient’s son is not present to assist with translation, a translator for her preferred language should be acquired so that the patient has full comprehension of the care that is being delivered and that she will be receiving. Furthermore, the patient’s current financial situation should be taken into account when considering her treatment plan since her major form of income is her late husband’s disability payments and pension. Therefore, she may not be able to afford the costs of the recommended prescriptions.

As for this patient’s treatment plan, she should continue on her current medications of a thiazide diuretic, ACE inhibitor, and Atorvastatin 10mg since they are managing her hypertension and elevated cholesterol levels effectively. However, there should be a change in her diabetes management since her recent A1C reading is 7.8%. Her current pharmacological management of Metformin 2000mg/day is not sufficient to manage her diabetes. According to the American Diabetes Association (ADA), the target goal A1C reading for individuals with diabetes is less than 7% to indicate that their diabetes is well-controlled (ElSayed et al., 2024).

To lower her A1C levels to the recommended target goal established by the ADA, an additional medication should be prescribed to this patient. According to the ADA, the recommended medication class for patients with moderate to high ASCVD risk is GLP-1 RA medications such as Semaglutide (ElSayed et al., 2024). The benefit of this class of medications is that they are very effective in lowering A1C levels, safe for cardiovascular risk patients, aids with weight loss, and reduces fatty liver (Samson et al., 2023). However, the drawbacks with GLP-1 RA medications are the expensive cost and the risk for medullary thyroid carcinoma (Samson et al., 2023). The other recommended medication class for patients with moderate to high ASCVD risk is SGLT2i medications such as Empagliflozin (ElSayed et al., 2024). The benefit of this class of medications is that they are very effective in lowering A1C levels, safe for cardiovascular risk patients, aids with weight loss, and potentially reduces fatty liver (Samson et al., 2023). However, similarly to GLP-1 RA medications, the drawbacks of SGLT2i medications are the expensive cost and the risk for medullary thyroid carcinoma (Samson et al., 2023). A third treatment option for this patient would be DDP-4 medications such as Sitagliptin (ElSayed et al., 2024). The benefit of DDP-4 medications is that they are more affordable than GLP1/SGLT2 and lowers A1c levels 0.6-0.8% as monotherapy (Samson et al., 2023; Gomez-Peralta, 2018). However, the drawbacks of this medication class is that they are not as effective as GLP1/SGLT2 in lowering glucose levels, are at moderate risk for CHF, and have a moderate to severe hypoglycemia risk (Samson et al., 2023). To determine which additional medication is best suited for this patient, a discussion should be made with the patient about all the potential recommendations as well as consider her health insurance costs for the recommended medications to estimate what her costs would be.

To assist this patient with costs for diabetes medications and supplies, resources should be provided. One organization to recommend to this patient is Affordable Diabetic (https://affordablediabetic.org/), which is a nationwide program that offers diabetic supplies at a reduced cost. Another organization is the American Diabetes Association Co-Pay Relief Program (https://copays.org/funds/diabetes/), which offers individuals financial assistance with deductibles, co-pays, and coinsurance for diabetes-related medications and healthcare services. In addition, the patient should also be educated about NeedyMeds (https://www.needymeds.org/pap), a national nonprofit organization that assists patients in finding assistance programs that may help them with medication and healthcare costs.