Number 1 post: PA

Q1. Which classes of diabetes medications are either weight neutral or cause weight loss? Please give one (1) example of a drug's generic and trade name in that class.

Type 2 diabetes (T2D) has been recognized as a bi hormonal disorder, with insulin and glucagon exerting opposite effects on glucose metabolism. Lang, et al., (2015). GLP-1-based diabetes therapies affect glucose control through several mechanisms, including slowed gastric emptying, regulation of postprandial glucagon, reduction of food intake, and enhancement of glucose-dependent insulin secretion without the risk of hypoglycemia. Chia-Hung, et al., (2015). One of the medications in the GLP-1 class is Exenatide with a generic name Byetta. In clinical trials, Sub Q injection of Exenatide (Byetta) 5 or 10ug was taken twice daily before the two largest meals of the day produced a modest decrease in fasting blood glucose and a large decrease in postprandial blood glucose. However, patients did not gain any weight and much lost weight. Rosenthal, & Burchum (2021).

Q2. Based on the current guidelines of the ADA, it would be appropriate to treat her with monotherapy since the patient is hesitant to take any injections. What agent would you recommend? Please provide the trade name, generic name, the dose you would start the patient with frequency, and route.

 It is appropriate to treat this patient with monotherapy. Metformin is a first-line treatment for T2DM that has been used for over 60 years. Upon ingestion, approximately 50% of metformin is absorbed primarily from the duodenum and jejunum, and systemically available metformin is renally excreted unchanged. Henry. (2018).

 I would recommend Metformin since it is the first-line therapy for Type 2 diabetes, it is  a medication in the drug class of Biguanide with a generic name Metformin (Glucophage). Patient will take 500 mg/tablet, once a day, taken orally with food.

Q3. What are the contraindications of your selected diabetic therapy?

Liver and renal dysfunction and heart failure and severe metabolic acidosis for the patient with significant renal impairment. Rosenthal, & Burchum. (2021).

The patient returns to your office six months later complaining of fatigue for the past two months, constipation, and heavy, irregular menses. Upon examination, you note that her skin is dry, and her fingernails are brittle. You suspect she has hypothyroidism.

Q4. What lab workup should you obtain? What sort of results will you see in patients who have hypothyroidism and hyperthyroidism?

The lab work-up I will obtain during this patient visit will be her thyroid hormone test. Which include: TSH (thyroid-stimulating hormone), T4 (Thyroxine). Free T4 is preferred and Free T3 (Triiodothyronine).  TSH, T3, and T4 can be used to diagnose, monitor, and treat thyroid disorders. Low T3, T4, and high TSH levels are seen with hypothyroidism, whereas high freeT3, T4, and Low TSH levels may indicate hyperthyroidism.

Q5. What is the treatment of choice for hypothyroidism? What is the mechanism of action? Please provide the initial dose, trade, and generic name of the drug, route, and frequency.

I will prescribe medication with the brand name Synthroid and a generic (Levothyroxine)50mcg PO daily with a max dose of 300mcg/day. Levothyroxine is the most used medicine. Hypothyroidism (2018). Levothyroxine increases metabolic rate, decreases thyroid-stimulating hormone (TSH) production from the anterior lobe of the pituitary gland, and, in peripheral tissues, is converted to T3. Thyroxine is released from its precursor protein thyroglobulin through proteolysis and secreted into the blood where is it then peripherally deiodinated to form triiodothyronine (T3) which exerts a broad spectrum of stimulatory effects on cell metabolism. (Physiology, Thyroid Stimulating Hormone Pirahanchi).

Q6. What are the adverse effects, and what important teaching will you provide this patient on thyroid replacement therapy?

Side effects include fever, hot flashes, sensitivity to heat, sweating, headache, nervousness, irritability, nausea, sleep problems (insomnia).

Patient will be informed that she will be prescribed the lowest dose possible that relieves her symptoms and brings her blood hormone levels back to normal. When starting on this medicine, the doctor may check the hormone levels every 2 to 3 months. After that, her thyroid hormone levels should be monitored at least once every year. Patients will be told not to stop taking the medicine even when she feels better, she needs to continue taking it exactly as the doctor prescribed. Thyroid medicine works best on an empty stomach and is taken 1 hour before any other medicines. I will also inform the patient that it may take one to three weeks after initiating therapy with levothyroxine or changing the dose before the effects are seen.

Number 2 post: BP

DMQ1. Classes of DM medications that increase weight loss are identified as GLP-1-RA and SGL2. An example of a GLP1-RA is Semaglutide with the brand name Ozempic (Higbea et al., 2017). An example of an SGL2 drug would be Empagliflozin sold as the brand name Jardiance (Higbea et al., 2017). Weight neutral DM medications include drugs such as Biguanides and DDP4i medications (Higbea et al., 2017). Biguanides include medications such as Glucophage which goes by the generic name Metformin. DDP4i medications include drugs such as sitagliptin, the brand name Januvia (Higbea et al., 2017).

Q2. The American Diabetes Association defines a hgbA1C above 6.5% as Diabetic (American Diabetes Association, 2022). The patient's hgbA1C is 8.4% which requires treatment (American Diabetes Association, 2022). The American Diabetes Association would suggest Metformin and lifestyle changes for this patient. Glucophage that goes by the generic name Metformin. Starting dose for this patient would be 500mg PO once daily (Lexicomp, 2021).

Q3. Precautions for this drug include decreased absorption post-bariatric surgery, renal impairment, hepatic impairment, heart failure, and increased stress levels (Lexicomp, 2021). Metformin products should be temporarily held for surgical procedures and studies using Iodine contrast, and the black box warning includes Lactic Acidosis (Lexicomp, 2021).

ThyroidQ1. The preferred test to run is a TSH (thyroid-stimulating hormone) level. The anterior pituitary is sensitive to changes in serum t3 and serum t4 levels, which can cause a rise in TSH levels (Rosenthal & Burcham, 2021). Other tests include the “serum thyroxine test” which measures T4 levels, both free and total (Rosenthal & Burcham, 2021). In addition, the “Serum Triiodothyronine Test” measures T3 levels free and total (Rosenthal & Burcham, 2021). Normal TSH levels range from 0.3-6, over 6 is reflective of hypothyroidism, and under 0.3 is indicative of hyperthyroidism (Rosenthal & Burcham, 2021). Hypothyroidism would include total T4 under 4.5, free T4 under 0.9, total T3 under 80, and free T3 under 230 (Rosenthal & Burcham, 2021). Hyperthyroidism would include ranges such as total T4 over 12.5, free T4 over 2, total T3 over 220, and free T3 over 620 (Rosenthal & Burcham, 2021).

Q2. The treatment of choice for Hypothyroidism is Levothyroxine also known as Synthroid (brand name). Hypothyroidism results in insufficient secretion of thyroid hormones including T4 (Correa & Eghtedari, 2021). Levothyroxine is the synthetic version of thyroid hormone T4. In a normally functioning thyroid, the anterior pituitary secretes TRH (thyroid- releasing hormone). TRH stimulates TSH (thyroid-stimulating hormone) which in turn stimulates the release of T4 (Correa & Eghtedari, 2021). T4 is then converted to T3 which is responsible for metabolism, cardiac function, and development (Rosenthal & Burcham, 2021). The starting dose of Levothyroxine is 1.6 mg/kg per day PO in the morning. Follow up with labs and titrate does up as necessary based on TSH levels.

Q3. Although side effects are rare, severe adverse reactions such as toxicity can occur which can include tachycardia, angina, tremor, nervousness, and insomnia (Rosenthal & Burcham, 2021). Patient teaching should include notifying the provider of any of these signs and symptoms. Toxicity is treatable with Cholestyramine, glucocorticoids, or PTU (Rosenthal & Burcham, 2021). Certain drugs accelerate the metabolism of Levothyroxine such as certain seizure medications and Zoloft (Rosenthal & Burcham, 2021). Levothyroxine increases the breakdown of Vitamin K (Rosenthal & Burcham, 2021). Therefore it should be used with caution for patients on Warfarin. It also increases the effects of catecholamines, increasing the risk for arrhythmia (Rosenthal & Burcham, 2021). It can also increase insulin and digoxin needs(Rosenthal & Burcham, 2021). Patients must understand that this medication cannot be skipped or discontinued without instructions and monitoring from a healthcare provider (Lexicomp, 2021). Education regarding medication administration includes taking medication on an empty stomach 30-60m before food in the morning, and 4hrs between calcium or iron-containing products (Lexicomp, 2021). It must be taken at the same time every day.