Posted: December 14th, 2022
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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.
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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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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|Core Defects Addressed||Generic Available
|CVD and CKD protection?||Renal Dose Adjustment||Nausea||Hepatic Glucose Production|
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|
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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