Seminar Case I - Type 2 Diabetes Mellitus Capstone

Seminar Case I: Type 2 Diabetes Mellitus 2-4 & 5-2025 Team_1__ Who’s missing_________________________________________________________ Names: Patient Presentation Chief Complaint “I have had diabetes for about six months and would like to have my blood sugar tested. I think that my blood sugar is running low because I have a terrible headache.” HPI A 45yearold woman who comes to the pharmacy for a diabetes education class taught by the pharmacist. She would like the pharmacist to check her blood sugar before the class begins. She was diagnosed with type 2 DM about 6 months ago, and her A1C was 8%. She had been attempting to control her disease with diet and exercise but had no success. She exercises once a week, and her diet is difficult to maintain due to being busy with her children’s schedules and having an erratic eating schedule at both work and home. Her physician started her on metformin 1000 mg twice daily with food about 3 months ago. She has gained 10 lb over the past year. She monitors her blood sugar once a day, and her results range from 200 to 230 mg/dL. Her fasting blood sugars have averaged 200 mg/dL. PMH ✔ Type 2 DM × 6 months ✔ HTN × 17 years ✔ Dyslipidemia × 12 years FH Father has a history of HTN, dyslipidemia, and bipolar disorder. Mother has a history of dyslipidemia and hypothyroidism. Brother has DM thought to be secondary to alcoholism. SH Has been married for 23 years. She has two children who are teenagers and one child in college. She works as a sales associate in the electronics department of a local mass merchandiser. She denies any use of tobacco products after stopping smoking 10 years ago but does drink alcohol occasionally (three beers or glasses of wine per week). Meds ✔ Lisinopril 20 mg PO once daily ✔ Metformin 1000 mg PO BID with food ✔ Pravastatin 40 mg PO once daily All Penicillin – hives ROS Complaints of nocturia, polyuria, and polydipsia on a daily basis. Denies nausea, constipation, diarrhea, signs or symptoms of hypoglycemia, paresthesia, and dyspnea. Physical Examination Gen WDWN severely obese, white woman in NAD (nothing abnormal discovered). VS BP 154/90 mm Hg, P 98 bpm, RR 18, T 37.0°C; Wt 109 kg, Ht 5′8″, waist circ 38″ HEENT PERRLA, EOMI, R&L fundus exam without retinopathy Neck/Lymph Nodes No LAN (lymphadenopathy) Lungs CTA (Computed tomography angiography) & P CV RRR, no m/r/g (Regular Rate and Rhythm, with No Murmurs, Rubs, or Gallops) Abd NT/ND (non-tender/non-distended) Genit/Rect Deferred MS/Ext Carotids, femorals, popliteals, and right dorsalis pedis pulses 2+ throughout; left dorsalis pedis 1+; feet show mild calluses on MTPs Neuro DTRs (deep tendon reflexes) 2+ throughout, feet with normal sensation (5.07 monofilament) and vibration Labs Na 138 mEq/L K 3.7 mEq/L Cl 103 mEq/L Ca 9.4 mg/dL Phos 3.3 mg/dL AST 16 IU/L Fasting lipid profile T. chol 244 mg/dL HDL 58 mg/dL CO2 31 mEq/L BUN 16 mg/dL SCr 0.9 mg/dL Random glu 223 mg/dL UA 1+ protein, (+) microalbuminuria ALT 19 IU/L Alk phos 62 IU/L T. bili 0.4 mg/dL A1C 9.2% LDL 141 mg/dL Trig 225 mg/dL TC/HDL ratio 4.2 ACR = 225 QUESTIONS Collect Information 1.a. What subjective and objective information indicates the presence of uncontrolled diabetes? ● Subjective : ○ Patient has a severe headache ○ Patient has hyperglycemia which it indicates she have uncontrolled diabetes ○ Polyuria ○ Nocturia ○ Polydipsia ○ She has attempted to control her diabetes with diet and exercise but has gained 10 lb over the past year ■ She exercises once a week ■ Her diet is difficult to maintain due to being busy and having an erratic eating schedule at work and home ○ She monitors her blood sugar once a day ■ results range from 200-230 mg/dL ■ fasting blood sugars averaged 200 mg/dL ○ She drinks alcohol occasionally (3 beers/glasses of wine per week) ● Objective: ○ Calculated BMI: 36.5 (obese category) ○ Calculated CKD-EPI creatinine equation (2021): 80 mL/min/1.73m2 ○ PMH: ■ type 2 DM (6 months) ■ hypertension (17 years) ■ dyslipidemia (12 years) ○ Fasting blood glucose is 200 mg/ dL ■ T2DM goal for non-pregnant adults fasting blood glucose is 80-130 mg/dL ○ Her blood glucose is consistently elevated (223 mg/dL) ○ A1C is elevated (9.2%) which it can indicated that she had chronic hyperglycemia ■ goal: <7% for diabetic patients ○ Blood pressure 154/90 mmHg which is not controlled ■ Goal: ≤130/80 mmHg ○ Dyslipidemia LDL: 141 mg/dL (Normal < 100 mg /dL) ■ Triglyceride : 225 mg/dL ● goal: <150 ■ Total cholesterol: 224 mg /dL ● goal: <200 ■ TC/HDL ratio = 4.2 ● at goal for T2DM (<5) ○ Kidney function: ■ Microalbuminuria ■ ACR=225 (Albumin to Creatinine Ratio) ● normal range: <30 mg/g ○ Current Medications: ■ lisinopril 20 mg PO once daily ■ metformin 1000 mg PO BID with food ■ pravastatin 40 mg PO once daily ○ Allergies: penicillin–hives 1.b. What additional information is needed to fully assess this patient’s diabetes? ● Physical activity (she exercise once a week, need more specific informations like intensity, duration and consistency of her exercise) ● Medication adherence (How consistent she is with her metformin and are there any barriers to adherence ● Dietary assessment: what is patients eating habits, is there any potential triggers for her poor blood glucose control and is there any way that we can keep that under control ● Patient education : Her her to have better understanding and knowledge about how to manage her diabetes ( self monitoring, carb counting) Assess the Information 2.a. Assess the severity of diabetes based on the subjective and objective information available? - A1C > 9% , indicating poor glycemic control. - symptoms of hyperglycemia (polyuria,nocturia,polydipsia). - presence of early diabetic nephropathy (proteinuria, ACR 225 mg/g). - Patient should be classified as an uncontrolled diabetic patient 2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety, and patient adherence. ● type 2 DM: uncontrolled - Add GLP-1 receptor agonist or SGLT2 inhibitor ● hypertension: blood pressure not at goal (154/90 mm Hg) aka uncontrolled - Increase her lisinopril 40 mg once daily. ● dyslipidemia: not at goal (LDL 141 mg/dL, T. chol 244 mg/dL, Trig 225 mg/dL). - Increase Pravastatin to 80 mg once daily. ● Diabetic Nephropathy ○ According to the national kidney foundation: ■ GFR category: G2 ■ ACR category: A2 ■ Risk of progression: moderate ○ Monitor with annual kidney evaluations ● Obesity ○ currently BMI > 30 Develop a Care Plan 3.a. What are the goals of pharmacotherapy for diabetes in this case? ● Diabetes: Per ADA Standards of care for Diabetes ○ A1C < 7% ○ Preprandial BG 80-130 mg/dL ○ 2-hr PPG <180 mg/dL ○ Bedtime BG goal: <150 mg/dL 3.b. What nondrug therapies might be useful for this patient’s diabetes? ● Diet changes ○ Limiting sugar-sweetened beverages, including natural fruit juices. ○ DASH or Mediterranean diet; low-carbohydrates, high-fiber. ○ Recommend seeing a dietician ● Exercise ○ 150 minutes of moderate-intensity aerobic exercise per week 3.c. What feasible pharmacotherapeutic options are available for treating this patient’s diabetes? ● Diabetes: addition of an SGLT2i along with a GLP1 RA would prove beneficial ○ Met + SGLT2i → due to pts current microalbuminuria and will help lower blood glucose levels ○ Met + GLP1 RA → greater effect in controlling weight loss while bringing down her A1C ○ Met + long acting insulin (lantus) 3.d. Create an individualized, patient centered, team based care plan to optimize medication therapy for this patient’s diabetes and other drug therapy problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy? ● continue metformin 1000 mg PO BID with food ● initiate ozempic inject 0.25mg SQ once weekly for 1 month (check in regard to food) ○ administer subcutaneous injection to abdomen, thigh, or upper arm at the same time of the day on the same day every week, with or without food ○ rotate injection sites weekly ○ Pen must be kept refrigerated ● As a clinical judgment to monitor the effectiveness of the GLP and to assess for side effects, due to patient’s adequate kidney function, an SGLT2i will be considered for additional therapy, after titrating Ozempic to 1 mg (by doubling her dose every 4 weeks and monitoring tolerability) ● Ozempic side effects & mitigation ○ side effects include nausea, vomiting, diarrhea, abdominal pain, decreased appetite, and constipation 3.e. What alternatives would be appropriate if the initial care plan fails or cannot be used? ● If SGLT2 inhibitors or GLP-1 receptor agonists are not effective or are contraindicated, we can use: ○ Sulfonylureas ( glimepiride): But it has a higher risk of hypoglycemia ○ DPP-4 inhibitors (Sitagliptin 100 mg PO daily) which it can be benefitalk for this patient because of her side effects and it can also lower the blood glucose Implement the Care Plan 4.a. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects? ● Patient should be educated on non-pharmacological strategies for managing diabetes and slowing the rate of comorbidity onset: ○ Work up to a goal of exercising ≥ 150 minutes/week (20-30 minutes ~ 5x/week) ○ Weight loss goal should be 7-10% of total body weight (~10 kg or 22 lb) ○ Continue cessation of smoking ○ Incorporate a diet of smaller portion sizes, limiting added sugars, saturated fats, and sodium ● Patient should be educated on the long-term comorbidities that is associated with T2DM and strategies to mitigate her risk factors ○ The most common comorbidities of T2DM: ■ Eye disease ■ Nephropathy (Kidney disease) ● Onset has begun, as indicated by (+) microalbuminuria ■ Brain disease (Stroke/CVA risk) ■ Heart disease (HTN, CAD) ■ Peripheral vascular disease 4.b. What screening tests does the patient need? ● Patient has received comprehensive screenings for the most common comorbidities of T2DM ● Example: Physical check of eyes/feet for neuropathy ○ Patient’s R&L fundus exam results showed no retinopathy ○ R doralis pedius pulses 2+ was normal, but L was only 1+ indicating a lower pulse & developing peripheral vascular disease ■ MONITOR Follow-up: Monitor and Evaluate 5. Explain how to monitor and evaluate the care plan for medication appropriateness, effectiveness, safety, and patient adherence by using clinical and laboratory data, patient feedback, and other information. ● Encourage the patient to keep a diet log ● Patients should keep a log of SMBG levels and bring it to the clinic upon follow-up ● A1C levels should be monitored every 3 months ● The patient should be asked about adherence and any side effects they are experiencing ● Annual, comprehensive diabetic foot exams to assess foot ulcer/amputation risks ● Annual dilated eye exams ● Monitor fasting metabolic panel every 3 months (every 4-12 weeks after therapy change/initiation) ● Annual kidney tests Additional questions: 6.a. If the patient still smokes cigarettes, what should you do? ● 5 A’s Recommend smoking cessation as it may be impacting their current health and exacerbating their current issues. ○ ask ○ advise ○ assess ○ assist ○ arrange ○ Only as a recommendation as of right now but explain benefits of quitting 6.b. If the patient is ready to quit smoking, what medications should you recommend? ● Bupropion can be used for smoking cessation and weight loss (with or without nicotine replacement therapy) ○ May be used as monotherapy or in combination with nicotine replacement therapy (Ref). Therapy should begin at least 1 week before the target quit date. Target quit dates are generally in the second week of treatment. If a patient successfully quits smoking, continue treatment for at least 12 weeks. ○ Dose: Bupropion XR: ■ Oral: ● Initial: 150 mg once daily for 3 days; increase to 150 mg twice daily (maximum dose: 300 mg/day). ● For patients who do not tolerate titration to the full dose, consider continuing 150 mg once daily; the lower dose has shown efficacy. ● Set a quit day ● Coping strategies: ○ withdrawal effects ● Nicotine replacement: ○ Long acting patch ○ Lozenge or gum for breakthrough ● All dosing should take into consideration # of cigarettes per day