patient, a 47-year-old male was diagnosed with Type 2 diabetes 12 months ago and is currently treated with lifestyle and metformin 1g twice daily. He lives alone, has had a previous myocardial infarction at the time of diabetes diagnosis but no documented evidence of heart failure. He has an HbA1c of 8% (64 mmol/mol), eGFR 70 mL/min/1.73 m² and BMI 33kg/m2. He is also prescribed atorvastatin 80mg, bisoprolol 5mg and ramipril 10mg.
With reference to published guidelines, consensus documents and evidence discussed during the module:
1. Justify whether you feel his glycaemic control should be intensified at this stage and if so, discuss what glycaemic target you would aim to agree with him and why.
2. List the additional ORAL hypoglycaemic agents you would consider recommending to him.
3. Outline the mode of action, benefits and potential risks of each treatment type to help him decide on additional therapy.
4. If there are therapies which you would not recommend, document these and explain why.
5. Allowing for joint decision making and based on individualization of therapy, present a detailed case for which drug you finally recommend he take. Ensure this recommendation is referenced to your chosen guideline/guidance.
Module 2 Essay
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Your patient, a 47-year-old male was diagnosed with Type 2 diabetes 12 months ago and is currently treated with lifestyle and metformin 1g twice daily. He lives alone, has had a previous myocardial infarction at the time of diabetes diagnosis but no documented evidence of heart failure. He has an HbA1c of 8% (64 mmol/mol), eGFR 70 mL/min/1.73 m² and BMI 33kg/m2. He is also prescribed atorvastatin 80mg, bisoprolol 5mg and ramipril 10mg.
With reference to published guidelines, consensus documents and evidence discussed during the module:
1. Justify whether you feel his glycaemic control should be intensified at this stage and if so, discuss what glycaemic target you would aim to agree with him and why.
2. List the additional ORAL hypoglycaemic agents you would consider recommending to him.
3. Outline the mode of action, benefits and potential risks of each treatment type to help him decide on additional therapy.
4. If there are therapies which you would not recommend, document these and explain why.
5. Allowing for joint decision making and based on individualization of therapy, present a detailed case for which drug you finally recommend he take. Ensure this recommendation is referenced to your chosen guideline/guidance.
Points of clarification
· There are five sections to this assignment and your answer should cover them all.
· Focus only on his glycemic management in this assignment.
· 50% of the marks are for analysis and evaluation so it is important for you to demonstrate this in each section of the assignment.
Rubric
UoW Essay_100 marks
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UoW Essay_100 marks |
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Criteria |
Ratings |
Pts |
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This criterion is linked to a learning outcomeKnowledge & Understanding |
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30 pts |
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This criterion is linked to a learning outcomeAnalysis & Evaluation |
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50 pts |
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This criterion is linked to a learning outcomeApplication |
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20 pts |
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Total points: 100 |
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(diabdec2026)
Introduction
As per the case presented concerning the 47-year-old male diagnosed 12 months ago with type two diabetes and is getting treatment with metformin 1g twice daily and lifestyle currently, further illustration indicates that the patient stays alone and had the previous history of the myocardial infarction at the moment of diabetes diagnosis however had no documented evidence of the heart failure. Moreover, the patient has an HbA1c of 8% (64 mmol/mol), eGFR 70 mL/min/1.73 m² and BMI 33kg/m2 and also prescribed atorvastatin 80mg, bisoprolol 5mg and ramipril 10mg.
Therefore, with the comprehensive HbA1c guidelines for monitoring the diabetes control, the WHO suggests the following diagnostic for the diabetic condition whereby the HbA1c of 48 mmol/mol or over (6.5%) or over indicates that the patient is type 2 diabetes, HbA1c below 42 mmol/mol (6.0%) indicates non-diabetic and HbA1c below 42, and 47 mmol/mol (6.0-6.4%) indicates pre-diabetes or the impaired glucose regulation. According to the WHO suggestions and the patient's condition, I feel that glycaemic control should be intensified.
Glycaemic control and glycaemic targets that agree with the patient
Significantly with the comprehensive information provided in the case study is with no doubt that the patient requires intensified glycaemic control since the patient diagnostic test reveals HbA1c of 8% (64 mmol/mol) above HbA1c of 48 mmol/mol or over (6.5%) that WHO suggest being type 2 diabetes. Impressively, glycemic control stands as a delicate balancing act within the diabetic patient. The patient is tasked with comprehensively maintaining the glycemic level of blood glucose, objective requiring education, voluntary control, decision-making strategies, and the extensive wisdom to prevent hypo and hyperglycemia conditions. Hence it is very significant to understand several considerations when setting in place glycemic targets (Jirapinyo et al., 2018). The American diabetes association commends the overall targets appropriate for several patients but emphasizes the individualization's significance based on the major patient characteristics. I, therefore, must ensure that glycemic targets must be personalized in the context of mutual decision making to comprehensively address the preferences and the needs of the patient and the significant individualistic characteristics that possibly can influence the risks and the merits of the therapy for the patient. Bearing the patient in the case study with less stringent control of HbA1c of 8% (64 mmol/mol) might be suggested if the life expectancy of this patient is in such a way that its merits of the intensive target may be unrealistic or if the stake and the challenges of the patients seem to overshadow the potential benefits.
American Diabetes Association suggests a more comprehensive relaxed goal of 8-8.5% for older patients with complicated medical concerns (Chamberlain et al.,2018). Since the patient is 47 years old with 8% of HbA1c, the ADA recommendation is supported by the evidence that the low HbA1c targets never minimize the risk of the comprehensive macrovascular complications VADT, ACCORD, and ADVANCE. Significantly stringent glycemic control augmented cardiovascular events, especially in patients experiencing hypoglycemic episodes. Importantly despite the risk associated with glycemic control, it should never be abandoned entirely in the older patient. However, better glucose control in an elderly patient has been linked to lowering the mortality rate following myocardial infarction and cognitive functioning enhancement. Another vital glycemic control target approach is metformin that decreases insulin resistance, reduces the gut reabsorption of glucose, reduces weight gain, prevents hepatic gluconeogenesis, and has been comprehensively linked to the decreased plasma lipid levels and blood pressure (Chamberlain et al.,2018).
Moreover, based on the evidence from the animal models, metformin is safe in the elderly as it can increase longevity. Therefore, encouraging stable glycemic control is to comprehensively prevent both the short-term and the long-term complications resulting from the type 2 diabetes patient. After that, the glycemic management target must be well recognized by all stakeholders in the management system. The patient's daily glucose outcome must be reviewed in the shift reports to develop the appropriate action to start and intensify the therapeutic modalities as required. The patient's condition must engage strategic interventions, including the comprehensive planning of diet, self-care education, pharmacological treatment, and the hypoglycemic prevention mechanism to assist the patient in the case study. Finally, the need to offer an update on the strategic intervention in controlling hypoglycemia and diabetes during the admission and sending the patient home with comprehensive safety and effective discharge plan is essential since the patient stays alone at home with medical complications (Khattab et al., 2010). Overall, nutrition plays an integral part in ensuring glycemic targets, whether in a hospital facility or at home.
Please list the additional ORAL hypoglycemic agents you would consider recommending to him.
Due to the prevalence nature of type 2 diabetes, the modern management of the condition varies depending on the patients' underlying conditions. Some of the underlying conditions majorly considered include age, pertinent history, health complications like heart failure, and lifestyle. The American Diabetes Association (ADA) proposes the following oral hypoglycaemic agents is suitable to the kind of patient we have in this study (a 47-year-old male diagnosed 12 months ago with type 2 diabetes):
· Meglitinides (repaglinide and nateglinide)
· DPP-4 inhibitors (sitagliptin, saxagliptin, vildagliptin, linagliptin, alogliptin)
· SGLT2 inhibitors (dapagliflozin and canagliflozin)
· Cycloset (bromocriptine)
The mode of action, benefits and potential risks
Mode of Action
· Meglitinides applies their actions through different pancreatic beta-cell receptors. They regulate adenosine triphosphate-sensitive potassium channels that are present in pancreatic beta cells, increasing insulin secretion.
· DPP-4 inhibitors hinder the enzyme dipeptidyl peptidase 4 (DPP- 4). They, therefore, deactivate glucose-dependant insulinotropic polypeptide (GIP) and glucagon-like peptide 1 (GLP-1). They regulate glucose through various effects like reducing glucagon secretion while increasing glucose-related insulin secretion, reducing gastric content.
· SGLT2 inhibitors hinder sodium-glucose co-transporter 2 (SGLT-2) in proximal tubules of renal glomeruli, resulting in inhibition of around 90% glucose reabsorption causing glycosuria in people with diabetes which lowers the plasma glucose levels.
· Cycloset, a sympatholytic dopamine D2 receptor agonist that reset the hypothalamic circadian rhythm that might have been changed by obesity. It results in the reversal of insulin resistance and a reduction in glucose secretion.
Potential risks
Despite health benefits obtained when these agents are administered, there are also potential risks one can experience as a result of using them. These are discussed below.
DPP4 inhibitors
Sitagliptin: Hypoglycemia (1%), nasopharyngitis (5%), causes an increment in serum creatinine, sudden pancreatitis (hemorrhagic or necrotizing forms), and acute renal failure. Saxagliptin: Peripheral oedema (4%), mild headache (7%), infection to the urinary tract (7%), mild lymphocytopenia (2%) and acute pancreatitis. Linagliptin: Increased uric acid (3%), increasing serum lipase (8%; more than three times the normal limit), nasopharyngitis (7%), and acute pancreatitis.
SGLT-2 inhibitors
Dyslipidemia (3%), hyperphosphatemia (2%), hypovolemia (1%), fungal vaginosis (7% to 8%), infection of the urinary tract (6%), increased urinal output (3% to 4%), dysuria (2%), influenza (2% to 3%), fracture to the bone (8%), end stage renal impairment, and nausea.
Cycloset
Causes dizziness, headache, constipation, rhinitis, nausea, and general body weakness. Results into an allergy response from the body.
Repaglinide
Hypoglycemia (16% to 31%), increase in weight, headache (9% to 11%), upper respiratory tract infection (10% to 16%), and cardiovascular ischemia (4%).
Potential Benefits
There are benefits that a type 2 diabetes patient gets when he/she takes oral hypoglycaemic agents. Each agent has its benefits. The benefits are discussed below:
DPP-4 inhibitors
It has a neutral effect on the patient's body weight and little risk of hypoglycaemia. However, when administered together with SU or insulin, these benefits are not experienced. They are, therefore, important for patients who are overweight and susceptible to hypoglycaemia. These benefits also help patients suffering from kidney disease and hemodialysis. The agent can serve in place of metformin for patients experiencing kidney diseases.
SGLT-2 inhibitors
It has cardiovascular and renal benefits, preventing heart disorder development and lower renal impairments in patients with T2DM. SGLT-2 inhibitors have glucose-lowering effects, too, and all these results in a reduction in the progression rate of diabetic kidney disorder. Helps in the reabsorption of more filtered glucose. Reducing SGLT2 protein lowers glucose reabsorption capacity in the proximal tubules, which lowers hyperfiltration by improving the sodium supply to the macula densa. That activates tubuloglomerular feedback (TGF). The resultant benefit is a vasoconstriction afferent arteriolar and low intraglomerular hyperfiltration. Finally, lowering glucose reabsorption reduces glucotoxicity in the organs and kidneys. It Reduces renal growth, inflammation and injury to the kidney.
Cycloset
It is used with diet and exercise. It improves blood sugar control in patients with type 2 diabetes mellitus. The increment in blood sugar control also helps the body balance sugar content, reducing risks and other health complications associated with type 2 diabetes.
Repaglinide
Even though there are no clear benefits of using this agent, a medical trial conducted by the American Geriatric Society revealed some benefits. The trial illustrated that older patients (ages 65 and above and 75 and below) years treated with repaglinide (up to 6mg) showed fewer hypoglycemic events than glibenclamide treatments. The study demonstrated that for patients with poor glycemic control and good health, repaglinide is safe and effective. It also has benefits like lowering the risk and frequency of hypoglycemia.
If there are therapies that you would not recommend, document these and explain why
Based on individual underlying health conditions, as in the patient's case study addressed here, some therapies may not be conducive in some patients. The patient has a history of myocardial infarction, a BMI of 33kg/m2 and stays alone at home. Therefore the therapies I wouldn't recommend are:
Repaglinide
It poses various adverse side effects to individuals who use it. Some of these risks include hypoglycemia (16% to 31%), weight gain, upper respiratory tract infection (10% to 16%) and cardiovascular ischemia (4%). Bearing in mind that our case study is a 47-year-old male with a history of myocardial infarction and has a BMI of 33kg/m2, it means that the patient is obese (overweight). Thus, exposing the patient to further risks would cause more complications to the patient. Again the patient is reported to have a possibility of cardiac complications, meaning upper respiratory infection coupled with cardiovascular ischemia would prove a threat to the patient. I, therefore, recommend the patient to be treated with alternative therapies.
Thiazolidinediones
This is another therapy I wouldn't recommend that the patient use. These are the side effects, such as hypoglycaemia (almost 27%) and cardiac failure (around 8%). These side effects mean that the patient should not be subjected to further risk factors. The cardiac failure condition will easily evoke since the patient has a history of myocardial infarction.
Allowing for joint decision-making and based on therapy's individualization present a detailed case for which drug you finally recommend he take.
Based on the patient's conditions, it is safe to base our decision on therapy's individualization since it is safe for our patient. The decision is on using the DPP-4 inhibitors. The therapy is strictly favourable to the underlying health conditions of the patient. Some of the benefits of making this appropriate include the neutral effect on the patient's body weight and little hypoglycaemia risk. The therapy would also enable the administration of other SU or insulin, making it suitable and safe for our patient. Moreover, the cost of this medication is also affordable. It also has a good acceptance level in the body.
Conclusion
Therefore, with a comprehensive analysis to achieve glycemic targets, the patient must undergo regular checkups when using the anti-diabetes medication drug to ensure a quality outcome. Another important concern is the lifestyle that usually takes centre stage in controlling type 2 diabetes. Meaning the patient needs to reevaluate the nutrition intervention to help him in glycemic management control.
References
Bowman, P., Sulen, Å., Barbetti, F., Beltrand, J., Svalastoga, P., Codner, E., Tessmann, E.H., Juliusson, P.B., Skrivarhaug, T., Pearson, E.R. and Flanagan, S.E., 2018. Effectiveness and safety of long-term treatment with sulfonylureas in patients with neonatal diabetes due to KCNJ11 mutations: an international cohort study. The lancet Diabetes & endocrinology, 6(8), pp.637-646.
Chamberlain, J.J., Johnson, E.L., Leal, S., Rhinehart, A.S., Shubrook, J.H. and Peterson, L., 2018. Cardiovascular disease and risk management: review of the American Diabetes Association Standards of Medical Care in Diabetes 2018. Annals of internal medicine, 168(9), pp.640-650.
Foretz, M., Guigas, B. and Viollet, B., 2019. Understanding the glucoregulatory mechanisms of metformin in type 2 diabetes mellitus. Nature Reviews Endocrinology, 15(10), pp.569-589.
Jirapinyo, P., Haas, A.V. and Thompson, C.C., 2018. Effect of the duodenal-jejunal bypass liner on glycemic control in patients with type 2 diabetes with obesity: a meta-analysis with secondary analysis on weight loss and hormonal changes. Diabetes care, 41(5), pp.1106-1115.
Khattab, M., Khader, Y.S., Al-Khawaldeh, A. and Ajlouni, K., 2010. Factors associated with poor glycemic control among patients with type 2 diabetes. Journal of Diabetes and its Complications, 24(2), pp.84-89.
Lebovitz, H.E., 2019. Thiazolidinediones: the forgotten diabetes medications. Current diabetes reports, 19(12), pp.1-13.
Moon, M.K., Hur, K.Y., Ko, S.H., Park, S.O., Lee, B.W., Kim, J.H., Rhee, S.Y., Kim, H.J., Choi, K.M. and Kim, N.H., 2017. Combination therapy of oral hypoglycemic agents in patients with type 2 diabetes mellitus. Diabetes & metabolism journal, 41(5), p.357.
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