Advanced Pharmacology NSG 533
1. 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 16
mg/dL, SCr 0.89 mg/dL, glucose 128 mg/dL; A1C 7.8%
Based on EP's profile above, which of the agents would be able to obtain
an A1C goal of less than 7% and would be appropriate in the patient?
Please provide an explanation of appropriateness or lack thereof.: 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 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%
2. 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 2 6 3 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 diabetes. Which drug
therapy would be the best for JR to trial?
Discuss your opinion of JR's lipid management.
Discuss your opinion of JR's blood pressure management.: Metformin is
the drug of choice recommended for most patients with 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
1. 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 16
mg/dL, SCr 0.89 mg/dL, glucose 128 mg/dL; A1C 7.8%
Based on EP's profile above, which of the agents would be able to obtain
an A1C goal of less than 7% and would be appropriate in the patient?
Please provide an explanation of appropriateness or lack thereof.: 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 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%
2. 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 2 6 3 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 diabetes. Which drug
therapy would be the best for JR to trial?
Discuss your opinion of JR's lipid management.
Discuss your opinion of JR's blood pressure management.: Metformin is
the drug of choice recommended for most patients with 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
