N720 Case Study Three: Adult Diabetes
Terra S. Beek
N720
Spring 2018
The University of North Carolina
School of Nursing
Diabetes and A1C Goal
As a diagnosis, diabetes mellitus (DM) is growing at an alarming rate, and, judging by the current lifestyle habits, this trend will continue to rise (Kountz, 2013). In fact, it is the most common endocrine disorder (Golden, Thomas, & Porter, 2015, p. 875). This disorder brings with it not only increased risks for adverse outcomes (affecting multiple body organ systems), but also a significant financial burden.
Maintaining one’s blood sugar within therapeutic levels is key for patients with DM. Mr. Franco had an A1C of 8.7% that now is 7.6%. Though improved, this is still not within the guidelines (American Diabetes Association ADA, 2015). The glycemic target for a patient who is nonpregnant with a diagnosis of diabetes mellitus given no other extenuating circumstances is a hemoglobin A1C less than seven percent (ADA, 2015).
Management
Mr. Franco unfortunately has known risk factors for developing diabetes, including his ethnicity (Latino), age (greater than 45 years of age), stress level, and inability to find adequate time to exercise (Golden, Thomas, ; Porter, 2015, p. 889). All factors must be considered not only when initiating individualized therapy in a patient, but also when adding adjuvant treatments to existing therapy. Diet and exercise should always be encouraged at every stage in a disease/disorder process, and thus finding a way to support Mr. Franco’s physical activity and nutrition are key (such as consultation with a nutritionist or dietary specialist).
Though Mr. Franco has a normal creatinine level and no proteinuria was detected in his urine, his blood, urea, nitrogen (BUN) is slightly elevated at 23. There is no recorded glomerular filtration rate (GFR) from the patient’s visit, however one can be roughly estimated. A GFR of 93 was calculated using the patient’s creatinine, age, gender, and race (UKidney, 2018). A GFR above 90 is normal or reassuring. Serum creatinine is shown to be a more valid indicator than BUN (Prabhakar, 2012). As Mr. Franco’s BUN is slightly elevated, adequate hydration should be encouraged in diet.
This patient is on the recommended first line treatment for DM at the usual effective dose of Metformin—1000 milligrams (mg) twice a day—but it is obvious another adjuvant therapy is needed to help him reach his glycemic goal (McCulloch, 2018). Multiple options exist for adjuvant therapy for Mr. Franco, including but not limited to adding a sulfonylurea, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a thiazolidinedione, a sodium glucose cotransporter 2 (SGLT2) inhibitor, glucagon-like peptide-1 (GLP-1) receptor agonist, and insulin, among others (Whalen, 2015). Sulfonylureas carry the risk of weight gain and hypoglycemia (Whalen, 2015). Thiazolidinediones have an increased risk for liver toxicity (Whalen, 2015). Adding an SGLT2 inhibitor would prove beneficial (regarding cardiovascular health and weight loss), but it brings the risk of genitourinary infections, ketoacidosis, the possibility of hypotension and orthostasis when initiating the medication, and metabolic acidosis (Avogaro, Delgado, ; Lingvay, 2017).
Given this, the favorable treatment at this stage is adding an incretin mimetic, namely a GLP-1 receptor agonist to Mr. Franco’s regimen (Lexicomp Online ®, 2018). GLP-1 receptor agonists are preferred over DPP-4 inhibitors as they can be advantageous for weight loss, produce a greater reduction in blood glucose levels, and significantly aid A1C goals (Reid, 2012). In addition, GLP-1 receptor agonists can reduce cardiovascular markers including lipids and blood pressure (Reid, 2012). In patients who are struggling with obesity, GLP-1 receptor agonists are generally preferred for improved long-term outcomes (Brunton, 2014). Though GLP-1 medications do have these noted benefits, this drug may cause Mr. Franco to have a recurrence of abdominal discomfort as this medication can delay gastric emptying (Raz, 2013). A lowered dose of liraglutide (Victoza) can be initiated at 0.6 (mg) to offset this gastrointestinal side effect with an eventual dose escalation to 1.2 mg or even 1.8 mg if need be (over incremental weeks) (Monthly Prescribing Reference MPR, 2018). Further, the risk of hypoglycemia is very low with a GLP-1 receptor agonist (Dungan & DeSantis, 2018).
Victoza (liraglutide) is a subcutaneous injection. It is important to ascertain Mr. Franco’s readiness and ability to self-inject medications with needles. Teaching is key; proper cleaning, proper technique, safe storage of the medication and needles, and safe disposal of the needles are key points to discuss with the patient. Mr. Franco should also be educated in the proper subcutaneous areas to inject (top of the thigh, abdomen, back of the arm) and to rotate the injection sites. Utilizing the teach-back method and demonstration would be useful for the patient. Studies show that administering the first injection with healthcare personnel in the office helps with most anxiety (Brunton, 2014). It is also very important to make sure he has subcutaneous needles to use. Victoza should be used with Novo Nordisk subcutaneous needles, and a savings program is even available for those who quality for a discount on both Victoza and Novo Nordisk needles (Novo Nordisk, 2018). In some instances, a prescription for subcutaneous needles may also even be given.
Liraglutide can cause gastrointestinal side effects such as diarrhea or constipation, vomiting, nausea, headache, skin irritation, and lowered appetite. (Lexicomp Online ®, 2018). More serious side effects include risk of thyroid C-cell tumors, pancreatitis, renal or hepatic impairment, gallbladder disease, or a more serious allergic reaction (MPR, 2018). Routine blood work (especially liver and kidney function) should be monitored with the patient’s follow-up, as should his A1C. Educating Mr. Franco on the side effects and adverse reactions are key. Further, signs and symptoms of hyperglycemia and hypoglycemia (feeling dizzy, weak, shaking, or confusion) should always be reviewed, especially when adding another medication to the patient’s regimen.
Mr. Franco should wear a medical alert identification on his wrist, should not share his pen or cartridge devices with another person, and should throw away needles in a needle or sharp disposal box (Lexicomp Online ®, 2018). The patient should not use the drug if the medication appears discolored or cloudy, should implement hand hygiene before and after administration, and should attach a new needle before each dose (Lexicomp Online ®, 2018). Unopened pens should be stored in a refrigerator (Lexicomp Online ®, 2018).
The patient is being given three Victoza pens with instructions to start at a dose of 0.6 mg for one week and then increase the dose to 1.2 mg for the second week. The patient should follow all instructions given in the package insert, and can turn the dose selector on the pen to the allocated dose in mg. Mr. Franco should follow-up in clinic in approximately one to two weeks to assess his response to the medication, his ability to adhere to the therapy (self-injections), and to ascertain whether a dose adjustment—or change in medication—may ultimately be needed.
Insurance and Treatment
Insurance is a very important factor when considering not only if the patient can acquire said medication, but if he or she will continue taking it. Mr. Franco has a stable, steady job and has health insurance, so adding adjuvant therapy is feasible. However, if Mr. Franco did not have insurance, a medication such as a GLP-1 receptor agonist would not be realistic as this medication can be expensive—even upwards of hundreds of dollars (MPR, 2018). For some patients, life without health insurance is a reality, and for those who do not have the financial means, another adjuvant therapy such as a sulfonylurea (glimepiride) may be more economically suitable (Lexicomp Online ®, 2018). Utilization of coupons or savings programs are always advisable for patients.
Other Therapy Indicated
Mr. Franco has an Atherosclerotic Cardiovascular Disease (ASCVD) ten-year risk score of 17.6%. Given this, his risk factors, and his hyperlipidemia, this patient would benefit from a medium to high-dose statin. Per the American College of Cardiology and American Heart Association’s guidelines on the treatment for blood cholesterol to reduce ASCVD risk, individuals who have DM, are aged 40 to 75 years old, have a low-density lipoprotein (LDL) between 70 to 189 mg per deciliter, and an estimated ten-year ASCVD risk of 7.5% of greater should be on a high-intensity statin. To this end, atorvastatin should be started at a prescription dose of 40 mg daily, and if this dose can be tolerated (especially given the gastrointestinal side effects), then the patient can titrate up to 80 mg daily (Lexicomp Online ®, 2018).
Atorvastatin can cause hepatotoxicity, rhabdomyolysis, a slight elevation in hemoglobin A1C, gastrointestinal side effects, myopathy/arthralgia, and nasopharyngitis (Lexicomp Online ®, 2018). Educating Mr. Franco on the side effects and adverse reactions are key. Liver and kidney function should be monitored with this drug at the patient’s follow-up. The patient should be instructed to adequately hydrate (drink at least two liters of water a day), avoid excessive alcohol, and avoid grapefruit juice. The patient is being given a one-month course of atorvastatin to assess his response to the medication and to ascertain whether a dose adjustment may be needed.
Tarheels Clinic
1234 University Lane
Chapel Hill, North Carolina 27514
(919) 123-4567
Dorothy Preceptor, DNP, RN, PNP
Approval: 714484512
Patient: FF Birthdate: 06/03/1963 March 13, 2018
657 Peachtree Road, Chapel Hill, NC 27514
Age: 55 YO
Rx: Victoza (liraglutide) injection, 18 mg/3 mL (6 mg/mL)
Sig:
Week 1 Inject 0.6 milligrams subcutaneously once a day for seven days
Week 2 Inject 1.2 milligrams subcutaneously once a day
Quantity: 3 pens
Refills: 0
Signature: Terra S. Beek, MSN, RN, FNP
Supervising Physician: Ramses Pride, MD
This medication is being started in addition to your metformin. Please continue taking your metformin as prescribed. Inject this medication subcutaneously (into the top of your thigh, abdomen, or back of your arm) daily. It may be taken with or without food. Turn the dose selector on the pen to the allocated dose in mg. Inject 0.6 mg subcutaneously once daily for approximately one week (seven days). The following week (on day eight) inject 1.2 mg subcutaneously once daily. Wash hands and site before each injection, use a new needle with each dose, and dispose of needles in a sharps container. Do not use the medication if it looks cloudy or discolored. Store unopened pens in a refrigerator. Continue to monitor your blood sugar while taking this medication.
Common side effects include gastrointestinal side effects such as diarrhea or constipation, vomiting, nausea, headache, skin irritation, and lowered appetite.
Serious side effects are less common but may include risk of thyroid tumors (hoarseness, lump in the throat or neck), moderate-severe abdominal pain (pancreatitis, gallbladder disease, or liver problems), kidney impairment (trouble using the bathroom or discolored urine), or hypersensitivity reactions. If you have any of these symptoms, present to an emergency department for treatment and inform your provider as soon as possible.
Tarheels Clinic
1234 University Lane
Chapel Hill, North Carolina 27514
(919) 123-4567
Dorothy Preceptor, DNP, RN, PNP
Approval: 714484512
Patient: FF Birthdate: 06/03/1963 March 13, 2018
657 Peachtree Road, Chapel Hill, NC 27514
Age: 55 YO
Rx: Lipitor (atorvastatin calcium), 40 milligram tablets
Sig: Take one tablet by mouth every morning. Take with or without food. Do not chew tablet, swallow whole.
Quantity: 30 tablets
Refills: 0
Signature: Terra S. Beek, MSN, RN, FNP
Supervising Physician: Ramses Pride, MD
This medication is being started in addition to your metformin and newly prescribed Victoza. Please continue taking these medications as prescribed. This medication should be taken every morning. It may be taken with or without food but should be swallowed whole and not chewed. Take the same prescribed dose every day. Avoid excessive alcohol and grapefruit juice with this medication. Continue to monitor your blood sugar while taking this medication.
Common side effects include diarrhea, joint pain, nose or throat irritation, and nausea.
Serious side effects are less common but may include liver (dark urine, light-colored stools, confusion, stomach pain, throwing up, yellow eyes) or kidney (blood in the urine, pelvic pain, fever) dysfunction, hypersensitivity (blistered skin, wheezing, tightness in the chest, lip swelling), muscle pain with urinary symptoms, or weakness, one-sided facial droop, blurry eyesight and/or memory problems. If you have any of these symptoms, present to an emergency department right away for treatment and inform your doctor as soon as possible.
References
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American College of Cardiology. (2018). ASCVD risk estimator plus. Retrieved from
http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
American Diabetes Association. (2015). Glycemic targets. Diabetes Care, 38(1), S33-S40.
Retrieved from http://care.diabetesjournals.org/content/40/Supplement_1/S48
Brunton, S. (2014). GLP-1 receptor agonists vs. DPP-4 inhibitors for type 2 diabetes: is one
approach more successful or preferable than the other? International Journal of Clinical Practice, 68(5), 557-567. doi:10.1111/ijcp.12361
Dungan, K. ; DeSantis, A. (2018). Glucagon-like peptide-1 receptor agonists for the treatment
of type 2 diabetes mellitus. In J. E. Mulder (Ed.), UpToDate. Retrieved March 15, 2018, from https://www.uptodate.com/contents/glucagon-like-peptide-1-receptor-agonists-for-the-treatment-of-type-2-diabetes-mellitus?topicRef=1790;source=see_link#H19
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Lexicomp Online ® (2018). Atorvastatin. Hudson, Ohio: Lexi-Comp, Inc.: March 14, 2018.
Lexicomp Online ® (2018). Glimepiride. Hudson, Ohio: Lexi-Comp, Inc.:March 15, 2018.
Lexicomp Online ® (2018). Liraglutide. Hudson, Ohio: Lexi-Comp, Inc.: March 14, 2018.
McCulloch, D. K. (2018). Management of persistent hyperglycemia in type 2 diabetes mellitus.
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McCulloch, D. K. (2018). Metformin in the treatment of adults with type 2 diabetes mellitus. In
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UKidney. (2018). eGFR calculator. Retrieved from https://ukidney.com/nephrology-
resources/egfr-calculator
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