Assignment: Diabetic Case Study
Assignment: Diabetic Case Study
Assessment:
Diabetes type II
Hypertension
[elementor-template id="165244"]Hyperlipidemia
Obesity
Plan:
Pharmacologic:
- Metformin 850 mg orally once daily with meals.
- Hydrochlorothiazide (HCTZ) 25 mg per oral once daily.
- Atorvastatin 20 mg per oral once daily.
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Provide rationale:
Metformin is an oral hypoglycemic under the class of Biguanides. I selected metformin because it decreased endogenous insulin production by enhancing the body’s sensitivity to insulin (Lv & Guo, 2020). It is an ideal hypoglycemic agent for Marion because she is overweight. Metformin does not promote an increase in weight. Besides, it is increasingly the drug of choice in overweight patients with type 2 diabetes. It does not also cause hypoglycemia and is thus ideal for this patient (Lv & Guo, 2020). Metformin will aim to lower the HbA1c level to below 7.0%.
HCTZ is a thiazide diuretic used in the management of hypertension. It is indicated as an initial antihypertensive treatment for the general non-black population, including those with diabetes (Hripcsak et al., 2020). HCTZ is an ideal antihypertensive to lower the patient’s blood pressure to below 140/90 mmHg. The rationale for prescribing HCTZ will be to lower and maintain blood pressure below 140/90 mm Hg and prevent hypertension complications such as stroke.
Atorvastatin is a lipid-lowering agent under the class of HMG-CoA Reductase Inhibitors. It is recommended as an adjunct to diet in managing elevated total cholesterol and triglyceride levels and increasing high-density lipoproteins (HDL) in patients with primary hypercholesterolemia (Last et al., 2017). Therefore, Atorvastatin is an ideal statin for Marion based on high Total cholesterol and triglyceride levels and low HDL levels. A HDL level below 40 mg/dl is a cardiovascular risk factor in addition to Type 2 diabetes (Last et al., 2017). Atorvastatin is an ideal drug to reduce the patient’s risk of stroke and heart attack due to cardiovascular risk factors.
Non-Pharmacologic
- Dietary changes: Studies have documented a connection between sodium chloride intake and blood pressure. The patient will be advised on a moderate reduction in sodium chloride dietary intake to promote a reduction in blood pressure (Aronow, 2017). She will also be educated on the DASH diet to help lower blood pressure and blood glucose levels and promote weight loss. In addition, she will be instructed to avoid a very high-fat diet and intake of high concentrations of refined carbohydrates to increase HDLs and lower total cholesterol and triglyceride levels (Last et al., 2017). Total fat intake should be limited to promote weight loss. Reducing fat intake promotes the desired weight loss and improves triglyceride levels.
- Physical activity: Regular aerobic physical activity promotes weight loss, lowers blood pressure, decreases insulin resistance, improves cardiovascular conditioning, and decreases the overall risk of cardiovascular disease. The American Diabetes Association (ADA) recommends: At least 150 minutes/week of moderate-intensity aerobic physical activity; or 75-150 minutes/week of vigorous-intensity aerobic physical activity; or an equal combination of moderate and vigorous-intensity aerobic activity (De Boer et al., 2017). It also recommends muscle-strengthening activities on two or more days a week.
The patient will be advised to engage in moderately intense physical activities such as brisk walking and jogging for 30 minutes a day, five days per week. According to Aronow (2017), weight loss through exercise and the DASH diet results in a large decrease in blood pressure and cardiovascular risk biomarkers.
- Self-monitoring of blood glucose and blood pressure. The patient will be trained on self-monitoring of blood glucose and pressure to monitor response to treatment (De Boer et al., 2017). She will also be educated to identify abnormal levels and when to seek a medical consult. She will be instructed to tracking glucose levels before, during, and after exercise. Monitoring the glycemic response to exercise helps to direct insulin and carbohydrate consumption to prevent incidences of hypoglycemia and hyperglycemia (De Boer et al., 2017). According to the ADA, all hypertensive patients with diabetes should monitor blood pressure at home to rule out white-coat hypertension.
- Treatment adherence: The patient will be advised on adhering to the treatment regimen to promote the desired glycemic, cholesterol, and blood pressure levels (De Boer et al., 2017). The patient will be educated on the mechanism of action of each drug, its benefits, and potential side effects to promote adherence.
- Alcohol restriction: The patient will be advised to restrict alcohol consumption since it promotes weight gain and increases blood pressure. Low levels of alcohol intake have a favorable effect on blood pressure, while intake of three or more drinks per day is related to an elevation of blood pressure (Aronow, 2017). Daily alcohol consumption should be restricted to less than 30 mls of ethanol in men and 15 mls in women.
- Foot care: The patient will be educated on foot care, including how to clean, dry, and protect her feet from injury to avoid foot ulcers and amputations.
Diagnostics:
- HbA1c- The patient’s HbA1c will be monitored every three months to establish the patient’s response to Metformin therapy and lifestyle modification (ADA, 21018).
- Blood cholesterol: The blood cholesterol level will be monitored every six months to check HDL, LDL, triglyceride, and Total cholesterol levels (Last et al., 2017). The test will help in determining if therapy with Atorvastatin is effective as well as lifestyle modification.
- Liver function tests: The patient will have periodic liver function tests because statin use such as Atorvastatin may cause an increase in the level of liver enzymes (Last et al., 2017).
Follow Up: The patient will be followed up after two weeks to monitor response to therapy. The follow-up will involve monitoring blood pressure, glycemic levels, and weight. Health education will be emphasized and the patient assessed for any medication-associated side effects.
Referral: The patient will be referred to a nutritionist for nutrition counseling and advice on calories restriction based on her weight and cholesterol levels.
She will be referred to an endocrinologist if there are difficulties in achieving adequate glycemic and lipid control to review the treatment plan and assess any diabetes complications (ADA, 2018).
Referral to a nephrologist since the patient has significant proteinuria to assess renal diabetes complications.
Referral to an ophthalmologist annually for complete retinal examination to assess for microvascular diabetes complications.
MOA: Metformin inhibits hepatic and renal gluconeogenesis and stimulates glucose in peripheral tissues (Lv & Guo, 2020). It also slows glucose absorption from the gastrointestinal tract and reduces plasma glucagon levels. HCTZ inhibits the re-absorption of sodium in the distal renal tubules. This results in increased excretion of water, sodium, potassium, and hydrogen ions (Hripcsak et al., 2020). Atorvastatin is an HMG-CoA reductase inhibitor. It acts by inhibiting the rate-limiting step in cholesterol biosynthesis by competitively inhibiting HMG-CoA reductase.
Absorption: Metformin has a bioavailability of 50-60%. The peak plasma time is 2-3 hours for regular-release and 4-8 hours for extended-release (Lv & Guo, 2020).
HCTZ is not very lipid-soluble and should be administered in fairly large doses (Hripcsak et al., 2020). The onset of HCTZ in hypertension is 3-4 days and has 65-75% bioavailability.
Atorvastatin has a bioavailability of 14%, an onset of 3-5 days, and a duration of 48-72 hours.
Distribution:
Metformin is minimally protein bound. HCTZ is protein-bound at 40-68%. Atorvastatin is protein-bound at 98%.
Metabolism:
The liver does not metabolize metformin. HCTZ is minimally metabolized (Hripcsak et al., 2020). Atorvastatin is metabolized via hepatic P450 enzyme CYP3A4.
Excretion:
Metformin has a half-life of 4-9 hours, excreted through urine with 90% by tubular secretion (Lv & Guo, 2020). HCTZ has a half-life of 5.6-14.8 hours and is excreted through urine. Atorvastatin has a half-life of 14 hours and is excreted mostly via bile and about 2% via urine.
SIDE EFFECTS:
The most common side effect of Metformin is GI distress with nausea, vomiting, abdominal distension, heartburn, and diarrhea (Lv & Guo, 2020). Side effects of HCTZ include anorexia, confusion, dizziness, fatigue, and headache (Hripcsak et al., 2020). Side effects of Atorvastatin include diarrhea, nasopharyngitis, arthralgia, nausea, and insomnia.
Pertinent drug/drug interaction: Atorvastatin should not be prescribed with cyclosporine, gemfibrozil, lonafarnib, and pazopanib.
Black box warnings: Metformin may cause lactic acidosis, which is potentially severe. It manifests with elevated blood lactate levels greater than 5 mmol/L, reduced blood pH, electrolyte disturbances with an elevated anion gap, and an elevated lactate/pyruvate rate (Lv & Guo, 2020). Risk factors for metformin-related lactic acidosis include: Age 65 years old or above; Renal impairment; Hypoxic states; Concomitant use of drugs such as carbonic anhydrase inhibitors; Having a radiological study with contrast; Surgery; Excessive alcohol consumption; Hepatic impairment.
References
American Diabetes Association. (2018). 4. Lifestyle management: standards of medical care in diabetes—2018. Diabetes care, 41(Supplement 1), S38-S50. https://doi.org/10.2337/dc19-S005
Aronow, W. S. (2017). Lifestyle measures for treating hypertension. Archives of medical science: AMS, 13(5), 1241–1243. https://doi.org/10.5114/aoms.2017.68650
De Boer, I. H., Bangalore, S., Benetos, A., Davis, A. M., Michos, E. D., Muntner, P., … & Bakris, G. (2017). Diabetes and hypertension: a position statement by the American Diabetes Association. Diabetes care, 40(9), 1273-1284. https://doi.org/10.2337/dci17-0026
Hripcsak, G., Suchard, M. A., Shea, S., Chen, R., You, S. C., Pratt, N., … & Schuemie, M. J. (2020). Comparison of cardiovascular and safety outcomes of chlorthalidone vs. hydrochlorothiazide to treat hypertension. JAMA internal medicine, 180(4), 542-551. https://doi.org/10.1001/jamainternmed.2019.7454
Last, A. R., Ference, J. D., & Menzel, E. R. (2017). Hyperlipidemia: drugs for cardiovascular risk reduction in adults. American family physician, 95(2), 78-87.
Lv, Z., & Guo, Y. (2020). Metformin and its benefits for various diseases. Frontiers in Endocrinology, 11, 191. https://doi.org/10.3389/fendo.2020.00191
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