NSG-533 Diabetes/Endocrine Topic Discussion

NSG-533 Diabetes/Endocrine Topic Discussion

Module II: Diabetes/Endocrine Topic Discussion

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Often we see a great deal of misinformation in the care of patients with diabetes, and often this misinformation is centered around the role and choice of medications.  Many patients, especially newly diagnosed patients, are prescribed medications that do not fit into the scheme of the ADA / AACE guidelines / best evidence based practices – for instance, starting on Januvia (sitagliptin) or Jardiance (empagliflozin) or Byetta (exenatide) as initial monotherapy without a compelling indication or reason.

In this discussion, please talk about how patients get put on these medications and why/how they should be transitioned to more evidence based treatments NSG-533 Diabetes/Endocrine Topic Discussion.  

• Is it okay to start a patient on a drug (particularly an oral drug) other than metformin as an initial drug?  Please cite possible circumstances where this could be reasonable.
• What anti-diabetic medications have compelling evidence for use in select populations, possibly as initial therapy, and is this benefit a “class” effect?
  • (eg. SGLT2Is – Patients with type 2 diabetes and a high risk of cardiovascular disease had reduced risk of a cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke relative to those randomized to receive placebo)
• How can patients and practitioners be convinced to change their behavior and opt for more evidence based approach to therapy?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

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• • Discussion 2
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  • Dianne Cohen posted Sep 9, 2020 7:58 PM
  •    Diabetes mellitus is one of the largest epidemics the world has faced and according to the International Diabetes Federation (IDF), in 2015 there were 415 million people affected by the disease (Zimmet et al., 2016). The four types of diabetes include; Type 1 diabetes accounting for 5-10% of all diabetic patients and is due to autoimmune B-cell destruction, type 2 accounting for 90-95% of all diabetes and is due to a progressive loss of adequate B-cell insulin secretion, gestational diabetes diagnosed during pregnancy, and diabetes due to other medical conditions (ADA, 2020). For patients with a contraindication, according to Flory and Lipska, sodium-glucose co-transporter 2 (SGLT-2 inhibitors) such as Jardiance and glucagon-like peptide 1 receptor agonists (GLP-1) such as Trulicity could be considered (2019). Their use is supported by clinical trials of thousands of patients in the modern context of antiplatelet, statin, and blood pressure management. However, newer drugs have primarily been studied as add-on therapy to metformin in patients with cardiovascular disease ( Flory and Lipska, 2019). Another important option for patients who can not take metformin is sulfonylureas (SUs/glinides) such as Glucotrol and Diabeta due to there cost-effective nature. However, they are also contraindicated in patients with acute liver injury and CKD (Flory and Lipska, 2019). There is not a consensus on which agents to use when metformin is not acceptable, and an individualized approach is recommended (ADA, 2020). At the same time, the American Association of Clinical Endocrinologists (AACE) lists non-metformin preferences in order with GLP-1 RAs listed first and dipeptidyl peptidase 4 (DPP-4 inhibitors) as the second, for monotherapy (Goldman-Levine, 2015, p.689). In addition, the use of metformin in hospitalized patients is controversial and historically patients are managed using a sliding scale insulin regimen which has no proven benefit (Kodner et al., 2017) NSG-533 Diabetes/Endocrine Topic Discussion. Its continued use during hospitalization is primarily due to dietary changes, medication changes, and acute illness which all worsen hyperglycemia (Kodner et al., 2017).  In conclusion, there is an array of medications for treating diabetes, however, metformin’s robust safety data appears to give it an advantage over other medications. In the absence of any contraindications, is the primary care provider always justified in its selection?                                                             ReferencesCowie, C. C. (2019). Diabetes diagnosis and control: Missed opportunities to improve health. Diabetes Care, 42(6), 994-1004. doi:10.2337/dci18-0047  
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  • Zimmet, P., Alberti, K. G., Magliano, D. J., & Bennett, P. H. (2016). Diabetes mellitus statistics on prevalence and mortality: Facts and fallacies. Nature Reviews.Endocrinology, 12(10), 616-622. doi:http://dx.doi.org.wilkes.idm.oclc.org/10.1038/nrendo.2016.105
  • Kodner, C., Anderson, L., & Pohlgeers, K. (2017). Glucose Management in Hospitalized Patients. American Family Physician, 96(10), 648–654.
  • Flory, J., & Lipska, K. (2019). Metformin in 2019. JAMA: Journal of the American Medical Association, 321(19), 1926–1927. https://doi-org.wilkes.idm.oclc.org/10.1001/jama.2019.3805
  • Goldman-Levine, J., (2015). Combination Therapy When Metformin is Not an Option for Type 2 Diabetes. Annals of Pharmacotherapy, 49(6), 688-699. https://doi-org.wilkes.idm.oclc.org/10.1177%2F1060028015572653
  • American Diabetes Association. (2020). Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes, 43(Supplement 1): S14-S31. https://doi.org/10.2337/dc19-S002
  • Clearly, it is incumbent upon the primary care provider to use the latest evidence-based research from reputable and credentialed associations such as the ADA and the AACE when deciding which medication is best for their patient NSG-533 Diabetes/Endocrine Topic Discussion. Additionally, it requires a thorough discussion with the patient and also taking into account the patient’s medical history, lifestyle, and finances.
  • Disproportionately, patients with chronic hyperglycemia are at risk of developing serious complications such as heart disease, blindness, limb amputations, and kidney failure due to microvascular damage (Zimmet et al., 2016). Fortunately, with prompt treatment, and screenings such as fasting plasma glucose (FPG) and a glycated hemoglobin test (A1C), primary care providers can detect and slow the progression of diabetes. (Cowie, 2019). With unlimited access to information, patients will sometimes self diagnose and request a medication based on a popular television commercial. Not quite as well known to patients but having a long track record is metformin also known as Glucophage to many. According to Flory and Lipska, metformin is the first-line pharmacologic treatment for type 2 diabetes and the most commonly prescribed drug for this condition worldwide due to its numerous studies and randomized clinical trials (2019). However, metformin can cause serious gastrointestinal disturbances and is not recommended in all patients especially those with chronic kidney disease (CKD), acute heart failure, and hepatic failure ( Flory and Lipska, 2019). Particularly, according to Goldman-Levine, metformin should be discontinued in patients with a glomerular filtration rate (eGFR)  less than 30 mL/min (2015).
  • Module Two- Tomiko Edmonds
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  • Tomiko Edmonds posted Sep 9, 2020 10:00 PM
  • Recent data indicates that 85.6% of adults with diagnosed diabetes are treated with Diabetes medication. Results from the National Health and Nutrition Examination Survey (NHANES) indicate that only about 50% of American adults with Diabetes are achieving HbA1c <7.0% (<53 mmol/mol) (Edelman & Polonsky, 2017). Modern day medicine and guidelines from the American Diabetes Association (ADA) have spent an enormous amount of time and resources to prove that certain classes of medications are best served to treat diabetes NSG-533 Diabetes/Endocrine Topic Discussion. It is argued that therapeutic interventions that target hyperglycemia but do not correct the underlying pathogenic disturbances are unlikely to result in a sustained benefit on the disease process, (Abdul-Ghani & DeFronzo, 2017).Metformin has been found to have additional benefits in its use. The addition of Metformin for patients with type 2 diabetes and a high risk of cardiovascular disease had reduced risk of a cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke relative to those randomized to receive placebo (Edelman & Polonsky, 2017). The use of SGLT2Is is now widely acceptable as a successful therapy to treat. For the first time, SGLT2 inhibitors offer a therapeutic approach acting directly on the kidneys without requiring insulin secretion or action, (Seufert, 2015).Diabetes, especially Type II Diabetes is a hot topic in my household as well as in my daily practice. I myself was diagnosed with type II Diabetes some years ago while pregnant. Over the course of several years, I was trialed on several therapies until I landed on the treatment that truly worked for me and this treatment, did not include medication therapy at all.                                                                                                                 ReferencesEdelman, S. V., & Polonsky, W. H. (2017). Type 2 diabetes in the real world: The elusive nature of glycemic control. Diabetes Care, 40(11), 1425–1432. https://doi.org/10.2337/dc16-1974Seufert, J. (2015). Sglt2 inhibitors – an insulin-independent therapeutic approach for treatment of type 2 diabetes: Focus on canagliflozin. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 543. https://doi.org/10.2147/dmso.s90662
  • Pharmacologic approaches to glycemic treatment: Standards of medical care in diabetes—2019. (2018). Diabetes Care, 42(Supplement 1), S90–S102. https://doi.org/10.2337/dc19-s009
  • Abdul-Ghani, M., & DeFronzo, R. A. (2017). Is it time to change the type 2 diabetes treatment paradigm? yes! glp-1 ras should replace metformin in the type 2 diabetes     algorithm. Diabetes Care, 40(8), 1121–1127. https://doi.org/10.2337/dc16-2368 NSG-533 Diabetes/Endocrine Topic Discussion.
  • The rate of compliance for a medication is directly correlated on the understanding of its use as well as the access to the medication at hand. Each practitioner and patient must be open to educating themselves on the risks versus the benefits of the medication as well as reading multiple, evidenced based studies that have been completed. These studies should not have been sponsored by organizations that have a stake in monetary gain. Patients need to understand that the medication they are taking is used for their benefit and must not cause additional harm to their physical being nor their finances.
  • Metformin is effective and safe, is inexpensive, and may reduce risk of cardiovascular events and death, (“Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2019,” 2018). While Metformin is an effective first line drug that offers several benefits such as cardiovascular protection, it lacks any effect on β-cell function, which is the primary pathophysiological disturbance responsible for progressive hyperglycemia in T2D patients, (Abdul-Ghani & DeFronzo, 2017). Medication and lifestyle changes should be introduced prior to adding a concomitant therapy. If this prescribed regimen is not successful, then other therapies may be introduced.  Studies on additional treatments have now been done to get to the root cause of the issue which is hyperglycemia NSG-533 Diabetes/Endocrine Topic Discussion.
  • Module 2-Karen Halter
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  • Karen Halter posted Sep 8, 2020 9:22 PM
  • Pharm Module 2 discussion Karen HalterFor patients unable to take metformin due to poor renal function, I would discuss the use of meglitinides in conjunction with low dose sulfonylureas. Taylor reports “The meglitinides have short half lives and relatively low rates of hypoglycemia. Repaglinide is hepatically metabolized to inactive metabolites and thus can safely be used in patients with renal insufficiency.” (Diabetes Medications in Renal Insufficiency, 2010) I feel careful renal monitoring and lower dose of a sulfonylurea would have a more protected outcome for renal function. Carlson, J. S. (2019). Type 2 diabetes therapies: A steps approach. American Family Physician. https://www.aafp.org/afp/2019/0215/p237.htmlDiabetes medications in renal insufficiency. (2010). Endochrinetoday. https://www.healio.com/news/endocrinology/20120325/diabetes-medications-in-renal-insufficiency
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  • Chisholm-burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., & Bookstaver, P. B. (2019). Pharmacotherapy principles and practice, fifth edition (5th ed.). Mcgraw-hill Education / Medical NSG-533 Diabetes/Endocrine Topic Discussion.

• References

• • As always, as prescribers we should always follow the evidence based approach-which currently is metformin, if not contraindicated and tolerated. I would also discuss at length lifestyle changes and non-pharmaceutical interventions like exercise, nutrition, and weight management.
  • The prevalence of diabetes in the United States is staggering. For newly diagnosed patients with Type 2 DM, metformin is considered the gold standard of therapy.(Chisholm-burns et al., 2019, p. 668) In an article in American Family Physician it was noted that metformin was still the number one drug of choice in initial therapy for Type2DM, utilizing the STEPS (safely, tolerability, effectiveness, price and simplicity).(Carlson, 2019) Metformin is contraindicated in patients with poor renal function (eGFR<30-45). (Chisholm-burns et al., 2019, p. 670)
  • Diabetes First Line Discussion
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  • Jessica Faltinowski posted Sep 9, 2020 2:10 PM
  • Diabetes Medication DiscussionThe goal of pharmacological interventions with diabetes is to decrease the blood sugar and the glycosylated hemoglobin, more commonly referred to as HbA1c or simply A1c.  An A1c of 5.7-6.4% indicates pre-diabetes and an A1c of 6.5% and greater by two separate tests is a confirmation of the diagnosis of diabetes type 2 (“2. Classification and Diagnosis of Diabetes,” 2014).  Initially a patient is encouraged to manage their diabetes through lifestyle modification, which is effective for some patients.  However, many patients find that this is not enough and need to begin medication.As many of these medications are relatively new, they are also much more expensive than metformin or second-generation sulfonylureas.  A practitioner needs to carefully analyze the risks versus benefits and review The American Diabetes Association’s (ADA) recommendations.  Metformin continues to be the most effective and least expensive medication to manage type 2 diabetes.  Metformin also has one of the lowest incidences of side effects.  Many patients see commercials on television for new diabetes medications and request them from their providers.  However, these patients are not generally aware of ADA recommendations, nor the cost of these medications.  Many are not covered by commercial drug plans or Medicare as they do not meet the recommendations.  All these factors must be taken into consideration as one prescribes medication.2. classification and diagnosis of diabetes. (2014). Diabetes Care, 38(Supplement_1), S8–S16. https://doi.org/10.2337/dc15-s005Hsia, D. S., Grove, O., & Cefalu, W. T. (2016). An update on sodium-glucose co-transporter-2 inhibitors for the treatment of diabetes mellitus. Current Opinion in Endocrinology & Diabetes and Obesity, 1. https://doi.org/10.1097/med.0000000000000311Kim, K.-S., Lee, B.-W., Kim, Y., Lee, D., Cha, B.-S., & Park, C.-Y. (2019). Nonalcoholic fatty liver disease and diabetes: Part ii: Treatment. Diabetes & Metabolism Journal, 43(2), 127. https://doi.org/10.4093/dmj.2019.0034Maruthur, N. M., Tseng, E., Hutfless, S., Wilson, L. M., Suarez-Cuervo, C., Berger, Z., Chu, Y., Iyoha, E., Segal, J. B., & Bolen, S. (2016). Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes. Annals of Internal Medicine, 164(11), 740. https://doi.org/10.7326/m15-2650
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  • Marín-Peñalver, J., Martín-Timón, I., Sevillano-Collantes, C., & Cañizo-Gómez, F. (2016). Update on the treatment of type 2 diabetes mellitus. World Journal of Diabetes, 7(17), 354. https://doi.org/10.4239/wjd.v7.i17.354
  • Jia, Y., Lao, Y., Zhu, H., Li, N., & Leung, S. (2018). Is metformin still the most efficacious first‐line oral hypoglycaemic drug in treating type 2 diabetes? a network meta‐analysis of randomized controlled trials. Obesity Reviews, 20(1), 1–12. https://doi.org/10.1111/obr.12753
  • Aroda, V. R., & Ratner, R. E. (2018). Metformin and type 2 diabetes prevention. Diabetes Spectrum, 31(4), 336–342. https://doi.org/10.2337/ds18-0020

• References

• • Evidence-based guidelines recommend metformin, a biguanide, as first-line monotherapy in diabetes type 2 (Jia et al., 2018).   According to Maruthur, metformin “inhibits hepatic gluconeogenesis through activation of adenosine monophosphate-activated protein kinases and induces glucose uptake into muscle cells” (2016, p. 9).  Simply put, metformin decreases inhibition of the enzyme that converts glycerol to glucose and increases insulin sensitivity.  However, like all medications, it is not without risk and is contraindicated in certain patient populations.  The use of metformin increases the risk of lactic acidosis and should not be used by patients with liver disease, including fatty liver disease or cirrhosis, or in patients with renal insufficiency (Aroda & Ratner, 2018). These patients should instead be started on a different initial medication.  The current recommendation for patients that concurrently have type 2 diabetes and nonalcoholic liver disease is pioglitazone (Kim et al., 2019).  Unfortunately, there are many unpleasant risks and side-effects with this medication such as weight gain, heart failure, myalgia, and an increased risk of upper respiratory infections and bladder cancer.  Patients who have cardiovascular disease or who are high risk for it, may benefit instead from a sodium-glucose co transporter-2 (SGLT2), as this latest class of approved medications for type 2 diabetes has cardioprotective factors and also can still be used while using a beta blocker such as metoprolol (Hsia et al., 2016).
  • The rise of diabetes mellitus (DM) type 2 has become a worldwide health crisis, affecting more than 400 million people (Marín-Peñalver et al., 2016).  Unlike type 1 diabetes mellitus, an autoimmune disorder, in which those affected do not produce sufficient insulin related to pancreatic beta cell destruction, the cause of type 2 diabetes has a significantly different pathology.  Type 2 diabetes is a chronic disease, thus more commonly seen as people age.  In this disorder, glucose is not taken into the cells and instead stays in the bloodstream causing hyperglycemia.  This disorder is often a combination of lifestyle and genetics.  Some patients have a genetic predisposition for type 2 diabetes; however, lifestyle contributes highly to not only the disorder, but also to its manageability.  Those who are obese or overweight, physically inactive, have hypertension, or a poor diet are much more likely to develop type 2 diabetes (Maruthur et al., 2016).
  • Discussion 2
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  • Carlita Lockett posted Sep 6, 2020 11:45 PM
  • In the nursing profession, most of our patients that we work with have diabetes or will develop diabetes during the time we know them. It is important that when prescribing medications that the nurse practitioner is aware of the pros and cons that go with the older medications to treat diabetes, as well, as the newer medications. Patients who have kidney and liver issues would be one of the groups of patients who shouldn’t use Metformin. Metformin has few adverse side effects, the most common adverse side effects being gastrointestinal symptoms (incidence rate 20-30%), including nausea and vomiting, and the most serious adverse effects being lactic acidosis (incidence rate 1/30,000), mainly in diabetic patients with liver and kidney dysfunction (Cheng et al, 2017) NSG-533 Diabetes/Endocrine Topic Discussion.
    Although many prescribers choose to use Metformin as an initial drug for diabetes, patients can be prescribed Farxiga and Jardiance. These two drugs specifically benefit the populations that have diabetes and complications of either atherosclerotic or cardiovascular disease and individuals who have kidney disease. These benefits could be listed as a “class” effect. Farxiga can be used in patients with atherosclerotic or cardiovascular disease and Jardiance can be used for individuals who have kidney disease. Based on a total of 145 events, dapagliflozin did not increase the hazard ratio (0.82; 95% CI 0.58 to 1.15) for the composite cardiovascular endpoint (defined as time to the first event of cardiovascular death, myocardial infarction, stroke, or hospitalization for unstable angina) compared with control arms (Bekiari et al., 2015).
    Patients and practitioners may find difficulty in choosing one of the newer anti-diabetic drugs for initial therapies because Metformin has been used for so long and proven to be effective. Throughout the education process, it could be introduced that conducting our own research using evidence-based data prior to practicing is acceptable and expected. We could also rely on evidence-based data upon completion of our degree in order to make sure we are providing the best treatment to our patients with the highest efficacy. As a patient, we need to be comfortable with challenging our providers and gathering our own information regarding which medications best suit us and our medical history. Practitioners and educators need to promote our patients to do research prior to beginning a new medication and asking specific questions.  This level of acceptance will help promote the use of evidence-based data to help patients and practitioners to make the best informed decisions.         with type 2 diabetes mellitus. Therapeutic advances in endocrinology and metabolism, 6(2), 61-67.Cheng, J., Feng, X., He, S., Huang, Luo, Y., Q., Tian, L., & Wang, Y. (2017). Metformin: A review of its potential indications. Drug design,       https://doi.org/10.2147/DDDT.S141675
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  •        development, and therapy, 11, 2421-2429.
  •        https://doi.org/10.1177/2042018814560735
  • Bekiari, E., Boura, P., Liakos, A., Karagiannis, T., & Tsapas, A. (2015). Update on long-term efficacy and safety of dapagliflozin in patients
  • Module 2 Discussion
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  • Augusta Ibeh posted Sep 9, 2020 4:48 AM
  •             Type 2 diabetes mellitus (DM) is a chronic metabolic disorder in which prevalence has been increasing steadily all over the world Olokoba, Obateru, & Olokoba (2012). Type 2 DM is usually as a result of lifestyle factors (lack of exercise, eating habit, choice of food) and genetic. Overweight has been the main influence on type 2 DM.
    • Glycemic goals should be individualized based on patient characteristics.
    • Antidiabetic treatment should be promptly intensified to maintain blood glucose at individual targets.
    • Combination therapy will be necessary for most patients.
    • Selection of agents should be based on individual patient medical history, behaviors, and risk factors, and environment.
    • Insulin is eventually necessary for many patients.

    Self-monitoring of blood glucose (SMBG) is a vital tool for day-to-day management of blood sugar in all patients using insulin and many patients not using insulin American Association of Clinical Endocrinologists (2019).            Cardiovascular disease (CVD), including heart failure (HF), is a leading cause of morbidity and mortality in people with type 2 diabetes mellitus (T2DM) Ali, Bain, Hicks, et al (2019). Individuals living with type 2 DM have comorbidities like high blood pressure, heart diseases as such the practitioners should consider the use of drugs that are very effective with less adverse side effects in the treatment of Type 2 DM with complications of heart diseases and renal conditions.            Many of the patients and care givers of individuals with type 2DM do not know how to access information on the treatment of the disease. This is as a result of socio-economic status, poor education, language barriers. Healthcare providers should use translators when taking care of patients with poor English proficiency. Handouts writing in many languages can also be used in health teachings especially on how to monitor blood sugar, medication administration, food preparations, portion sizes, exercise and how to take care of their foot. Patient’s referrals to dieticians, podiatrists and other specialists will help to provide adequate care and teachings to patients on Diabetic care and complications to lookout.            The barriers that face practitioners on utilizing evidence-based researches on patient’s care include lack of knowledge. Some practitioner’s failure to attend seminars to update their knowledge on recent research changes. Attitude towards learning new practice, some stick to the old practice before it has been working for the patients and there is no need for change. Hospital policy sometimes prevent practitioners from utilizing evidence-base practice in the care of patient NSG-533 Diabetes/Endocrine Topic Discussion .Reference            Ali, A., Bain, S., Hicks, D. et al. SGLT2 Inhibitors: Cardiovascular Benefits Beyond HbA1c—Translating Evidence into Practice. Diabetes The 10, 1595–1622 (2019). https://doi.org/10.1007/s13300-019-0657-8            Goderis, G., Borgermans, L., Mathieu, C. et al. Barriers and facilitators to evidence-based care of type 2 diabetes patients: experiences of general practitioners participating to a quality improvement program. Implementation Sci 4, 41 (2009). https://doi.org/10.1186/1748-5908-4-41            Schernthaner, G., Drexel, H., Moshkovich, E., Filiation, B., Martinka, E., Czupryniak, L., Várkonyi, T., Janež, A., Ducena, K., Lalić, K., Tankova, T., Prázný, M., Smirčić Duvnjak, L., Sukhareva, O., & Sourij, H. (2019). SGLT2 inhibitors in T2D and related comorbidities – differentiating within the class. BMC endocrine disorders, 19(1), 64. https://doi.org/10.1186/s12902-019-0387-y less0 UnreadUnread

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  • View profile card for Augusta Ibeh
  • Last post Sep 13, 2020 8:30 PM by Augusta Ibeh
  •             Olokoba, A. B., Obateru, O. A., & Olokoba, L. B. (2012). Type 2 diabetes mellitus: a review of current trends. Oman medical journal, 27(4), 269–273. https://doi.org/10.5001/omj.2012.68
  •             American Association of Clinical Endocrinologists (2019) https://www.aace.com/disease-state-resources/diabetes/depth-information/glycemic-management-type-2-diabetes
  • Lack or insufficient knowledge on the complications of DM and the important of lifestyle change, the fear of sticking self to check for blood sugar level and fear for insulin injections prevent patients from following evidence-based teaching.
  •             The sodium–glucose co-transporter-2 inhibitor (SGLT2) class of treatments include Januvia, (sitagliptin), Jardiance (empagliflozin) or Byetta (exenatide). In 2017, the American Diabetes Association had a meeting where several companies presented data on the effects of this group of these drugs in the treatment of Type 2 DM patients. Experts reviewed the data presented by researchers and the Federal Drug Administration (FDA) and the European Medicines Agency (EMA) and approved the use of three SGLT2 inhibitors for the treatment of Type 2 DM as an adjunct to diet and physical activity. These drugs are canagliflozin, dapagliflozin, empagliflozin Schernthaner et al. (2019).
  •             Type 2 DM management include change of lifestyle, diet modification and medications. The focus on the management of type 2 DM is to reduce and maintain the blood sugar level with the use glycemic drugs with few adverse side effects. These are the guidelines recommended by the American Association of Clinical Endocrinologists (AACE) and American Diabetes Association (ADA) to be considered while choosing treatment with the use of hyperglycemic drugs American Association of Clinical Endocrinologists (2019).
  • Discussion 2 with references re-formatted
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  • Carlita Lockett posted Sep 7, 2020 5:55 PM
  • In the nursing profession, most of our patients that we work with have diabetes or will develop diabetes during the time we know them. It is important that when prescribing medications that the nurse practitioner is aware of the pros and cons that go with the older medications to treat diabetes, as well, as the newer medications. Patients who have kidney and liver issues would be one of the groups of patients who shouldn’t use Metformin. Metformin has few adverse side effects, the most common adverse side effects being gastrointestinal symptoms (incidence rate 20-30%), including nausea and vomiting, and the most serious adverse effects being lactic acidosis (incidence rate 1/30,000), mainly in diabetic patients with liver and kidney dysfunction (Cheng et al, 2017) NSG-533 Diabetes/Endocrine Topic Discussion.
    Although many prescribers choose to use Metformin as an initial drug for diabetes, patients can be prescribed Farxiga and Jardiance. These two drugs specifically benefit the populations that have diabetes and complications of either atherosclerotic or cardiovascular disease and individuals who have kidney disease. These benefits could be listed as a “class” effect. Farxiga can be used in patients with atherosclerotic or cardiovascular disease and Jardiance can be used for individuals who have kidney disease. Based on a total of 145 events, dapagliflozin did not increase the hazard ratio (0.82; 95% CI 0.58 to 1.15) for the composite cardiovascular endpoint (defined as time to the first event of cardiovascular death, myocardial infarction, stroke, or hospitalization for unstable angina) compared with control arms (Bekiari et al., 2015).
    Patients and practitioners may find difficulty in choosing one of the newer anti-diabetic drugs for initial therapies because Metformin has been used for so long and proven to effective. Throughout the education process, it could be introduced that conducting our own research using evidence-based data prior to practicing. We could also rely on evidence-based data upon completion of our degree in order to make sure we are providing the best treatment to our patients with the highest efficacy. As a patient, we need to be comfortable with challenging our providers and gathering our own information regarding which medications best suit us and our medical history. Practitioners and educators need to promote doing research prior to begin a new medication and asking specific questions. This level of acceptance will help promote the use of evidence-based data to help patients and practitioners to make the best-informed decisions.       in patients with type 2 diabetes mellitus. Therapeutic advances in endocrinology and metabolism, 6(2), 61-67.Cheng, J., Feng, X., He, S., Huang, Luo, Y., Q., Tian, L., & Wang, Y. (2017). Metformin: A review of its potential indications.     https://doi.org/10.2147/DDDT.S141675
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  •      Drug design, development, and therapy, 11, 2421-2429.
  •       https://doi.org/10.1177/2042018814560735
  • References:
    Bekiari, E., Boura, P., Liakos, A., Karagiannis, T., & Tsapas, A. (2015). Update on long-term efficacy and safety of dapagliflozin
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  • Pawn Johnson-Hunter posted Sep 9, 2020 11:54 PM
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  • Evidence-based medicine and practices are often cited as being the drivers of clinical practice. However, there are barriers to unlearning that can inhibit what is considered to be instituted as evidence amongst various providers. One of the drawbacks to the reliability of evidence-based medicine is the quality of the evidence backing guidelines, and extensive studies are important factors in determining whether physicians will use such evidence to support their unlearning (Gupta et al., 2017). The management and control of glycated hemoglobin can dramatically decrease the risk of macrovascular and microvascular complications of diabetic patients. Type 2 diabetes (T2DM) is associated with a high risk of cardiovascular disease, renal failure, neuropathy, amputation, and blindness. Pharmacologic therapy for patients with T2DM continues to change often, adding new drugs and recommendations for maintaining glycemic levels.When deciding on the best treatment, the provider and patient must discuss the current lifestyle, other chronic illnesses, and affordability. Evidence-based practice should be largely taken into consideration as clinical trials have demonstrated the effectiveness of one therapy over another when it comes to T2DM with various medical conditions. When guidelines and randomized controlled trials (RCT) are not available, physicians use local data that they gather from their patient population to support unlearning (Gupta et al., 2017).Gupta, D. M., Boland, R. J., Jr, & Aron, D. C. (2017) NSG-533 Diabetes/Endocrine Topic Discussion. The physician’s experience of changing clinical practice: a struggle to unlearn. Implementation science : IS, 12(1), 28. Retrieved from https://doi.org/10.1186/s13012-017-0555-2

• • View profile card for Dianne Cohen
  • Last post Sep 13, 2020 1:06 AM by Dianne Cohen
  • Hu Y. (2019). Advances in reducing cardiovascular risk in the management of patients with type 2 diabetes mellitus. Chronic diseases and translational medicine, 5(1), 25–36. Retrieved from https://doi.org/10.1016/j.cdtm.2019.01.001
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  • One of the most common oral T2DM medications is metformin, which is considered to be the first line of therapy due to the effect of increasing glycolysis and inhibits gluconeogenesis and can also be used in patients that have a loss in islet function. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) treats hyperglycemia in patients with T2DM by reducing renal glucose reabsorption and increasing urinary glucose excretion, also causes natriuresis and is associated with an antihypertensive effect and weight loss(Hu, 2019). Some of the drugs known as SGLT2i’s are  canagliflozin (Invokana), dapagliflozin (Faxiga), empagliflozin (Jardiance) and, ertugliflozin (Steglatro) medication therapy options may be due to prescribers preference of drug along with the patient’s other comorbidities.
  • Module II: Diabetes/Endocrine Topic Discussion
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  • Robin Morgan posted Sep 7, 2020 11:45 PM
  • Module II: Diabetes/Endocrine Topic DiscussionEven with the disparities in the recommendations of the diabetes algorithms, the basic recommendation of both the AACE and ADA have major similarities that are evidence based. One thing all evidence agrees on is the first line of treatment should always be lifestyle modification, such as; weight loss, a diet low in carbohydrates and high in fiber, and exercise. Lifestyle modification should be ongoing and in addition to any other treatment. Starting patients on Metformin is the first medication for most patients, it’s a very effective drug and usually easily tolerated. If after 3 months of treatment with Metformin the patients A1C target is not obtained, moving on to dual medication therapy or even triple medication therapy may be necessary.(Wise, 2016) Combining the classes of hypoglycemic drugs with metformin is often the best path for a patient. Patients have a chronic illness, and after time the drug’s efficacy decreases. Eventually the patient’s body may not produce enough insulin, or stop producing all together and subcutaneous insulin may be needed. If a patients A1C is high enough, or oral medication is not being tolerated, insulin may need to be started sooner rather than later.Metformin is the best choice for first line treatment of type 2 diabetes, but it is not appropriate for every patient NSG-533 Diabetes/Endocrine Topic Discussion. Metformin may not be prescribed for those with chronic alcoholism, under active adrenal or pituitary glands, vitamin b 12 deficiencies, congestive heart failure, or end stage kidney or liver disease.(Migdal & Abrahamson, 2016) Metformin might be harmful to take with certain medications, clinicians should be aware of this list of medications when prescribing.There are so many drugs available today to treat type 2 diabetes it’s no wonder it’s hard to agree on the best medications for patients. Medications are advertised everywhere promising great things, and they all seem to have very catchy cute names. Patients may run to their doctors requesting to start on these medications. Clinicians and patients alike need to be educated on best practice in order to properly control hyperglycemia. The co morbidities to diabetes are numerous, so good control is important. Good blood sugar management starts with lifestyle modifications, then adding first line mono-therapy when needed. We have many drugs that can be added to Metformin to offer dual therapy or even triple therapy, but we must start with the foundation and advance the drugs with the disease. Informed clinicians can help educate patients and together a hyperglycemic control plan can be utilized using best practice for successful outcomes. Kaji, H. (2016). The current, emerging and future medications for type 2 diabetes and obesity. In Frontiers in clinical drug research: Diabetes and obesity (pp. 3–49). BENTHAM SCIENCE PUBLISHERS. https://doi.org/10.2174/9781681081854116020003Wise J. (2016). Metformin is backed as first line therapy for type 2 diabetes. BMJ 12236
  • View profile card for Gisselle Mustiga
  • Last post Sep 13, 2020 12:11 AM by Gisselle Mustiga
  • Victoza indicated for type 2 diabetes and moderate kidney diseases. (2015). The Pharmaceutical Journal.
  • Migdal, A.L. & Abrahmson, M.J. (2016). Treating type 2 diabetes mellitus. In Principles of diabetes mellitus (pp1-24). Springer International Publishing.

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• Obesity is the leading risk factor for type 2 diabetes, and many medications to treat diabetes cause further weight gain. One class of medication to treat hypoglycemia are GLP-1s, such as Victoza, Trulicity, and Byetta.  These drugs help promote weight loss, or at the very least, help prevent weight gain. They work for weight loss by slowing the movement of food through the digestive system, keeping patients feeling full longer.(“Victoza Indicated for Type 2 Diabetes and Moderate Kidney Disease,” 2015) These drugs also mimic the hormone leptin, making the brain trigger the feeling of satiety and fullness. These drugs all have the class effect of promoting weight loss.(Kaji, 2016) NSG-533 Diabetes/Endocrine Topic Discussion
• Following the algorithm for diabetes treatment has shown to be best practice for good patient outcomes, but physicians are often hesitant to order Metformin due to concerns about the drugs known risks. It has been noted that metformin may cause lactic acidosis. The drug should also not be used in patients with liver or kidney failure.  If physicians would review the latest evidence, maybe they would agree that the benefits far out way the risks.
• Healthcare professionals are inundated with many different choices of medications to treat type 2 diabetes. The American Association of Clinical Endocrinologists (AACE) and The American Diabetes Association (ADA) both attempts to streamline the treatment of diabetes, each by publishing a yearly algorithm to help clinicians manage type II diabetes. The fact that these two professional organizations do not combine research and publish one algorithm supports the fact that many of the recommendations are based on opinion, as many studies are in conflict with one another. Clinicians are tasked with deciphering through all of the research and utilizing the information to tailor plans based on their patient’s individual assessments and needs.
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• Gisselle Mustiga posted Sep 9, 2020 1:25 AM
• PModule II Discussion – DM/EndocrineAso, various anti-diabetic medications have provided compelling evidence for use in select populations. Some classes of the medications demonstrate cardiovascular (CV) protection, whereas some result from a class effect. The findings from different trials such as OUTCOME, UKPDS, SUSTAIN6, EMPA-REG, and LEADER have tested these medications’ efficacy and safety (Aldossari, 2018). The trials demonstrate that liraglutide, semaglutide, and EMPA have convincing effects on cardiovascular disease outcomes concerning mortality and morbidity. Other oral agents include sulfonylureas, SGLT2 inhibitors, thiazolidinediones, alpha-glucosidase inhibitors, and meglitinide analogs.ReferencesChaudhury, A., Duvoor, C., Reddy Dendi, V., Kraleti, S., Chada, A., & Ravilla, R. et al. (2017). Clinical Review of Antidiabetic Drugs: Implications for Type 2 Diabetes Mellitus Management. Frontiers In Endocrinology, 8. https://doi.org/10.3389/fendo.2017.00006
• View profile card for Carlita Lockett
• Last post Sep 12, 2020 10:30 PM by Carlita Lockett
• Irons, B., & Minze, M. (2015). Drug treatment of type 2 diabetes mellitus in patients for whom metformin is contraindicated. Diabetes, Metabolic Syndrome And Obesity: Targets And Therapy, 15. https://doi.org/10.2147/dmso.s38753
• Aldossari, K. K. (2018). Cardiovascular outcomes and safety with antidiabetic drugs. International journal of health sciences, 12(5), 70.
• There is a need for practitioners and patients to change their behavior and apply evidence-based approaches to therapy. Practitioners can achieve this by combining relevant research, clinical knowledge, and patient preferences to make healthcare decisions rather than relying on customs and opinions. It implies that practitioners need to have the ability to formulate a research question, locate relevant research, appraise the quality of research, and apply it after reevaluating its applicability. Treatment must be validated by scientific evidence.
• A great deal of misinformation really affects the care of patients with diabetes, especially with regard to the role and choice of medication to use on newly diagnosed patients. However, all medication decisions should rely on evidence-based practices, rather than just prescribing medications that do not meet the ADA / AACE guidelines. Leading recommendations consider metformin as an initial drug of choice for diabetes patients. Insulin is prescribed concomitantly when A_1c is over 9%. However, certain circumstances force practitioners to use other medications for such patients. Such exemptions include contraindications to its use or when patients cannot tolerate it because of adverse effects (Irons & Minze, 2015, p. 15). If another class of agent is used, there are several factors to consider when choosing another agent instead of metformin. According to Chaudhury et al. (2017), such factors include overall effectiveness in A_1c reduction, the profile of adverse effects, ease of use, costs or the patient’s financial situation, and patient preference (p. 15).
• Module 2- Diabetes/ Endocrine Topic Discussion
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• Anna McMullen posted Sep 8, 2020 8:38 AM
• Metformin is often considered to be first-line therapy for type-2 diabetes mellitus (T2DM) management  (Chisholm-burns et al., 2019) NSG-533 Diabetes/Endocrine Topic Discussion. When guidelines are created for diabetes management, factors such as efficacy, hypoglycemia risk, weight, side-effect profile, and cost come into the decision (Chisholm-burns et al., 2019, Table 43-2). With all of these factors considered, metformin makes sense for first-line monotherapy. Metformin has a well-established history; it is available in generic form (making it generally more affordable than other anti hyperglycemic alternatives), may cause weight loss, can be safely administered with other anti hyperglycemic medications, does not cause hypoglycemia, and addresses both fasting and post-prandial glucose levels (Bristol-Myers Squibb Company, 2017). However, although metformin is generally accepted as first-line monotherapy, there are other medication classes that should be considered for first-line monotherapy as well, in particular, GLP-1 RA’s.AACE/ ACE guidelines indicate that, in order of hierarchy of usage, that recommended mono therapy should be 1) metformin, 2) GLP1-RA, or 3) SGLT2i and if the patient has CVD or CKD that a GLP1-RA or SGLT2i be considered (2019). Providers often consider cost and ease of use when prescribing medications. A major drawback of the GLP1-RA class, until 2020, was that all GLP1-RA’s were injectables. However, with the launch of Rybelsus (oral semaglutide) the first oral GLP1- RA, a patient who is averse to an injection (daily or weekly) now has an oral option (Novo Nordisk, 2020) NSG-533 Diabetes/Endocrine Topic Discussion.

  	Core Defects Addressed	Generic Available (Cost)	CVD and CKD protection?	Renal Dose Adjustment	Nausea	Hepatic Glucose Production
  Metformin	3	Yes	No	Yes Do not take if CrCl < 30mL/s	9.9- 25.5% (Bristol-Myers Squibb Company, 2017)	Decreases
  GLP1-RA	6	No	Yes	No	14- 20%- Rybelsus (Novo Nordisk, 2020)	Decreases
  SGLT2i	2	No	Yes	Yes Do not take if CrCl < 30mL/s	1.1-2.3% Jardiance (Jardiance, 2020)	Increases*

  Patients and practitioners must look at and understand the pathophysiology of T2DM to understand how it occurs and therefore how it should be treated. What precipitates T2DM is insulin resistance. GLP1-RAs are the only class of medication to affect neurological hunger cravings and slow gastric-emptying, therefore leading to appetite suppression and weight loss (Thrasher, 2017). When discussing  the GLP1-RA class, it should also be noted that exenatide (Byetta- BID injectable/ Bydureon- weekly injectable) are only 50% identical to native GLP1 molecules (they are derived from gila monster lizards), whereas other GLP1-RAs including semaglutide (Ozempic-weekly injectable/ Rybelsus- daily oral), liraglutide (Victoza- daily injectable), and dulaglutide (Trulicity- weekly injectable) are > 90% identical to human GLP1 (Thrasher, 2017).  It is often thought that there is a class effect for the cardiovascular protection of GLP1-RAs and SGLT2is, however, individual trial design and indication differ in this conclusion. As with SGLT2is, CVD trials should not be compared with each other because of differing inclusion criteria, resulting in different cardiovascular indications (ie. Farxiga- reduction in hospitalizations, Invokana- reduction in hospitalizations due to heart failure, and Jardiance- reduction in MACE (major adverse cardiovascular events). According to a review conducted by Hinnen and Kruger (2019) which discussed the relationship between CVD and T2D and explored the findings of the latest CVOTs for antihypertensive medications they noted it seems unlikely that the CV benefits associated with Jardiance and Invokana is a class effect, but that there may be a class effect for heart failure. The diuretic effect of the SGLT2i class may help explain improvement in heart failure patients. In addition, not all GLP1-RAs have a CVD indication- Bydureon showed CVD safety but does not have an indication for reduction of MACE, whereas, Trulicity, Ozempic, and Victoza do (Hinnen & Kruger, 2019).ReferencesAmerican Association of Clinical Endocrinology & American College of Endocrinology NSG-533 Diabetes/Endocrine Topic Discussion. (2019). AACE/ACE COMPREHENSIVE TYPE 2 DIABETES MANAGEMENT ALGORITHM 2019 [Guidelines]. AACE. https://www.aace.com/pdfs/diabetes/AACE_2019_Diabetes_Algorithm_FINAL_ES.pdfChisholm-burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., & Bookstaver, P. B. (2019). Pharmacotherapy principles and practice, fifth edition (5th ed.). Mcgraw-hill Education / Medical.Hinnen, D., & Kruger, D. F. (2019). Cardiovascular risks in type 2 diabetes and the interpretation of cardiovascular outcome trials. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, Volume 12, 447–455. https://doi.org/10.2147/dmso.s188705Novo Nordisk. (2020). Rybelsus pi [PDF]. https://www.novo-pi.com/rybelsus.pdf more0 UnreadUnread

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• View profile card for Karen Halter
• Last post Sep 10, 2020 5:31 PM by Karen Halter
• Thrasher, J. (2017). Pharmacologic management of type 2 diabetes mellitus: Available therapies. The American Journal of Cardiology, 120(1), S4–S16. https://doi.org/10.1016/j.amjcard.2017.05.009
• Jardiance [PDF]. (2020). Boehringer Ingelheim Pharmaceuticals, Inc.. https://docs.boehringer-ingelheim.com/Prescribing Information/PIs/Jardiance/jardiance.pdf
• Glycemic management in type 2 diabetes. (2019). American Association of Clinical Endocrinologists. https://www.aace.com/disease-state-resources/diabetes/depth-information/glycemic-management-type-2-diabetes
• Bristol-Myers Squibb Company. (2017). GLUCOPHAGE (metformin hydrochloride) tablets [PDF]. FDA. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020357s037s039,021202s021s023lbl.pdf
• Alatrach, M., Laichuthai, N., Martinez, R., Agyin, C., Ali, A., Al-Jobori, H., Lavynenko, O., Adams, J., Triplitt, C., DeFronzo, R., Cersosimo, E., & Abdul-Ghani, M. (2020). Evidence against an important role of plasma insulin and glucagon concentrations in the increase in egp caused by sglt2 inhibitors. Diabetes, 69(4), 681–688. https://doi.org/10.2337/db19-0770
•             When it comes to management of T2DM, treating the disease and the overarching problem of addressing the eight core defects of T2DM, in order to prevent further progression of the disease is what should be considered when initiating monotherapy. No class of medication does this better than a GLP1-RA (excluding exenatide formulations and lixisenitide), which addresses more core defects than any other class, does not cause hypoglycemia, has the added benefit of weight loss and cardiovascular prevention, and has flexibility of dose scheduling and administration.
• It should be noted that SGLT2i respond to the side-effects of T2DM but do not address/ decrease any of the causative factors of the disease. Efficacy of SGLT2i’s is dependent upon renal function, since they work by decreasing the reabsorption of glucose by the kidneys by 30-50% and increasing glycosuria (Thrasher, 2017). T2DM is a progressive disease, where renal function typically deteriorates as the disease (as well as age) advances, making SGLT2is not a viable long-term solution in many cases. As noted in the chart above, SGLT2i’s increase hepatic glucose production, which is counterintuitive of what one would like to happen when managing T2DM. By promoting glucosuria, hepatic glucose production increases, leading to further insulin resistance. SGLT2is may pose a short-term solution to decreasing blood sugar levels, however, they do not provide a long-term solution to furthering the progression of T2DM NSG-533 Diabetes/Endocrine Topic Discussion.
• How does a provider decide on whether to prescribe metformin, a GLP1-RA, or an SGLT2i? The pros and cons of each class of medication should be considered:
• When treating T2DM, the eight core defects, known as the “ominous octet” should impact medication therapy, where the medication that will address the majority of these defects while safely and effectively managing hyperglycemia. The eight core defects of the ominous octet include: decreased insulin secretion (from the beta cells), decreased incretin effect (release of endogenous GLP-1), increased lipolysis (fat cells), increased glucose reabsorption (the kidneys), decreased glucose uptake (in the muscle cells), increased hepatic glucose production, neurotransmitter dysfunction, and increased glucagon secretion (in the alpha cells) (Thrasher, 2017). Metformin addresses three of the core defects (increased hepatic glucose production, decreased glucose uptake, and increased lipolysis) and GLP1-RAs address six of the eight core defects, all except for increased glucose reabsorption by the kidneys and increased lipolysis (Thrasher, 2017).
• Module 2 Candace Whitman-Workman
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• Candace Whitman-Workman posted Sep 9, 2020 10:29 PM
• Patients are started on SGLT2 inhibitors for a variety of reasons.  Ni et al. (2020) promotes the use of this drug classification for their cardiac and renal protecting factors.  These protection factors are class related and “not only reduce blood glucose but also protect the heart and kidney, which can significantly reduce cardiovascular events, delay the progression of renal failure, greatly improve the quality of life of patients, and reduce medical expenses for families and society” (Ni et al. 2020).   From personal experience, I had a provider who wanted to start me, without being diabetic, on a SGLT2 inhibitor simply for the weight loss benefit.  I’m not sure I agree with the provider’s methodology in this instance.  However, when patients have comorbid diseases or high risk factors for cardiovascular disease or kidney disease, it would be very appropriate to start an SGLT2 inhibitor as an initial monotherapy.  However, for those who do not have the same risk factors or are economically challenged, a SGLT2 inhibitor would probably not be the best drug of choice. Khazzaka M. (2019), suggests that physician prescribing habits are not only formed by gender, age, and location of their practice, but also by the marketing tactics of pharmaceutical companies.  Physician targeted marketing has been shown to influence prescribing decisions, often to the detriment of the patient as unnecessary medications are provided.  Pharmaceutical companies also use patient focused marketing leading to patients requesting certain medications from their physicians.  Pharmaceutical marketing earns big pharma a handsome payout.  Some ways to prevent this from happening is increased regulations for pharmaceutical companies.  Perhaps eliminate the gifts and samples and stick to factual education about the medication.  Training providers to think critically about medication choices and to think less about the reward pharmaceutical companies are offering.  For patients, factual education from their providers would be beneficial.  Regulation against pharmaceutical patient targeted marketing would be beneficial as well.Chisolm-Burns, M. A., S, Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, J. M., & Bookstaver, P. uB. (2019). Pharmacotherapy Principles & Practice (Fifth ed.). McGrraw-Hill Education.Khazzaka M. (2019). Pharmaceutical marketing strategies’ influence on physicians’ prescribing pattern in Lebanon: ethics, gifts, and samples. BMC health services research, 19(1), 80. https://doi.org/10.1186/s12913-019-3887-6Ni, L., Yuan, C., Chen, G. et al. SGLT2i: beyond the glucose-lowering effect. Cardiovasc Diabetol 19, 98 (2020). https://doi.org/10.1186/s12933-020-01071-y
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• Chisolm-Burns et al. (2019) indicate a patient centered approach is best and the provider should take into consideration factors such as meal schedules, history of post prandial hypoglycemia on other tried therapies, and the patient’s Hemoglobin A1c in determining what drug classification is best to use.  The choice is class specific rather than drug specific.
• Diabetic Medications Discussion
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• Kathryn Mosholder posted Sep 9, 2020 10:08 PM
•        In the article Pharmacologic Approaches to Glycemic Treatment :Standards of Medical Care in Diabetes (2019) they recommend to start patients on metformin first to assist in controlling blood sugars. If metformin is no longer tolerated due GI upset, vitamin B12 deficiency, peripheral nephropathy or liver disease patients should be considered for other types of medications (Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes, 2019). One of the other benefits to metformin compared to other drugs is the fact that other agents can be added to the medication regiment without contraindications (Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes, 2019).            With renal failure patients Metformin might not be the drug of choice depending on their GFR. Imam (2017) suggests not starting Metformin in a patient that has a GFR between 30-45 mL/min/1.73 m² due to the increased risk of renal acidosis. According to Betonico, Titan, Correa-Giannell, & Queiroz (2016) Biguanide-Metformin can still be used but not in stage 3-5 CKD. Two recommended medications that are safe for CKD patients are Sulfonylureas and Glinides (Betonico, 2016). However, with Glindies they include nateglinide which should be used with caution for patients with any type of renal injury (Betonico, 2016).         Management of diabetes mellitus in individuals with chronic kidney disease: therapeutic           https://doi.org/10.6061/clinics/2016(01)08       journal, 10(3), 301–304. https://doi.org/10.1093/ckj/sfx01      2019 American Diabetes Associationless0 UnreadUnread NSG-533 Diabetes/Endocrine Topic Discussion
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•       Diabetes Care Jan 2019, 42 (Supplement 1) S90-S102; DOI: 10.2337/dc19-S009
• Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes
• Imam T. H. (2017). Changes in metformin use in chronic kidney disease. Clinical kidney
•        perspectives and glycemic control. Clinics (Sao Paulo, Brazil), 71(1), 47–53.
• Betônico, C. C., Titan, S. M., Correa-Giannella, M. L., Nery, M., & Queiroz, M. (2016).
•             In conclusion, there are several options for oral medications for patients and depending on the situation some are better suited for the patient than others. Research is still being conducted to better determine which patients’ response better to different medications. Companies are developing new medications for diabetes at a rapid rate due to high population of diabetics. Practitioners are responsible for researching the best medications for their patients before prescribing them through reading evidence-based practice articles. Many times practitioners are influenced by the next up and coming drug and the drug reps that sell them. Taking a step back and remembering the patient’s well being is the approach that is needed regarding diabetic medication.
• When deciding on a diabetic oral agent several things must be considered including patient preference, cost, side effects, patient’s current medical conditions, and side effects (Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes, 2019). The medication regiment should be re-evaluated every 3 to 6 months with consideration of patient condition and an A1C should be drawn (Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes, 2019).
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• Shante Hunt posted Sep 9, 2020 7:05 PM
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• The decision to start an oral hypoglycemic can be difficult due to conflicting literature on appropriate initial or monotherapy.  While the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) both state that monotherapy can include Metformin, they differ in that the AACE also finds other options appropriate.  One class of medications offered by the AACE, DD-4 inhibitors such as vildagliptin, were found to decrease Hgb A1C by 0.8-0.9%  over a 24 week period versus a placebo group, however when compared to metformin, decrease in Hgb A1c was 1.0% versus 1.4% with metformin (Ahren, 2009). SGLT2 inhibitors such as Farxiga and long acting GLP1-RAs have been noted to be appropriate as monotherapy by the AACE if patients have high cardiovascular risks or chronic kidney disease (2020) but the risks associated with both classes of drugs are more significant than those of metformin.  Weight loss is a significant lifestyle modification that has been shown to improve management of diabetes mellitus, however sulfonylureas have poor evidence with regard to weight loss in contrast to SGLT2 inhibitors and GLP1-RAs which demonstrated a positive outcome on weight loss and blood pressure reduction (Wysham, 2018).  These benefits while encouraging, cannot be labeled as a class effect since these benefits cannot be generalized across the entire class, and some of the adverse effects range from mild to severe.Practitioners should be familiar with the research and data, including adverse effects of different classes of hypoglycemics so that patients can make informed decisions.  Comprehensive patient assessment which includes comorbidities related to renal and cardiovascular baseline function should be included in the decision to initiate monotherapy with medications other than metformin.ShanteReferences:Ahren, B. (2009). Clinical results of treating type 2 diabetic patients with sitagliptin, vildagliptin, or saxagliptin-diabetes control and potential adverse events. Best Practice & Research Clinical Endocrinology and Metabolism, 23(2009), 487-498.American Association of Clinical Endocrinologists. (2020). Consensus statement by the american association of clinical endocrinologists and american college of endocrinology on the comprehensive type 2 diabetes management algorithm-2020 executive summary. Endocrine Practice, 26(1), 107-139.  Retrieved from: https://www.aace.com/disease-state-resources/diabetes/clinical-practice-guidelines-treatment-algorithms/comprehensiveWysham, C. (2018). What’s new in the evolving management of type 2 diabetes: individualizing therapy with novel treatment options. Journal of Managed Care Medicine, 21(4), 47-52.  Retrieved from: http://web.a.ebscohost.com.wilkes.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=5&sid=9a4cff28-3775-43c6-b05a-4659aa15f0e2%40sessionmgr4008 NSG-533 Diabetes/Endocrine Topic Discussion