Classes of diabetes medications
An obese patient, age 45, comes to your office. She recently moved from another state three weeks ago and told you that her FNP diagnosed her with type 2 diabetes mellitus. She is currently not on any medicine for her diabetes, and she wishes to avoid insulin, if possible. She is a non-smoker. Her blood pressure is 138/74 mmHg. Labs from 3-weeks ago was hemoglobin A1C = 8.4%; total cholesterol = 260 mg/dL, triglycerides = 290 mg/dL, HDL = 49 mg/dL, LDL = 170 mg/dL (calculated 10-year ASCVD risk = 6.2%). You discuss current treatment goal recommendations endorsed by the ADA regarding glycemic control, blood pressure control, and lipid management. She agrees to start any medications that you recommend with lifestyle modification and a DASH diet to treat hypertension.
- The SGLT2 inhibitors and GLP-1 agonists are the two types of diabetes treatments that are weight-neutral in their effects.
- Metformin is a suitable option to start with because she is not on any other medications and because it is considered the first-line treatment by the American Diabetes Association. The dose I would recommend for her to begin with is 500mg twice daily taken orally. We will recheck her hemoglobin A1C in three months to see if it has decreased to a level that you are satisfied with at that time.
- Metformin is deemed safe even in persons with a history of hypertension. The use of insulin during childbirth is generally discouraged due to the increased risk of hypoglycemia.
- Continuous supervision of blood sugar levels will be necessary if it is discovered that insulin therapy is essential during pregnancy. Levothyroxine is the medicine of choice for the treatment of hypothyroidism.
- The medication’s mode of action entails giving a replacement source of thyroid hormone.
- A starting dose of 12.5 mcg/day should be administered.
Question 1 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.
- Two types of diabetes drugs that are either weight neutral or promote weight loss, depending on the dosage are SGLT2 inhibitors and GLP-1 agonists.
- Examples include the incretin mimetic liraglutide (marketed under the brand name Victoza) and the SGLT2 inhibitor empagliflozin (marketed under the brand name Jardiance).
Question 2 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.
- According to the American Diabetes Association (ADA) recommendations, the patient’s current A1C goal should be less than 7 percent. Given this patient’s reluctance to take insulin and an A1C of 8.4 percent, it would be prudent to begin with monotherapy in this case. Because this patient already has hypertension (138/74 mmHg), it is critical that she achieve her blood pressure goal as soon as possible.
- ADA recommends that people with diabetes and hypertension aim for a blood pressure of less than 130/80 mmHg. In non-pregnant people with diabetes and hypertension, lifestyle change, such as weight loss and exercise, is advised first line; however, pharmacologic treatment is indicated in patients who do not achieve their blood pressure objectives within 3-6 months.
- Based on the facts provided above, it is recommended that the patient be started on metformin (Glucophage), a generic biguanide medicine used to treat type 2 diabetes mellitus. Fasting plasma glucose concentrations can be reduced by roughly 20% with the use of metformin, according to research.
- It also has a favorable lipid profile, lowering triglyceride levels by around 20% while simultaneously boosting high-density lipoprotein (HDL) cholesterol levels , among other things.
Question 3 What are the contraindications of your selected diabetic therapy?
- Metformin is contraindicated in the presence of heart failure, renal insufficiency, or lactic acidosis (a rare but serious adverse event). Because of its tolerability and lack of association with weight gain or volume depletion, metformin is considered safe even in patients with a history of hypertension. This is despite the fact that it can cause hypoglycemia (and thus raise blood pressure) in patients with diabetes who also have high blood pressure.
- However, because the patient has not suffered any neuropathy, which is usually associated with vitamin B12 deficiency, it is unlikely that this is the case. The use of insulin during pregnancy is generally discouraged due to the increased risk of hypoglycemia, which is particularly prevalent in the third trimester. As a result, close monitoring of blood glucose levels will be required if it is found that insulin therapy is required during pregnancy in order to avoid unfavorable maternal/fetal outcomes.
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.
Question 4 What lab workup should you obtain? What sort of results will you see in patients who have hypothyroidism and hyperthyroidism?
- A serum TSH level as well as a free T4 level are measured as part of the lab workup. Hypothyroidism is characterized by low free T4 levels and elevated thyroid stimulating hormone (TSH). I would expect to find high free T4 levels and low TSH levels in patients with hyperthyroidism, which is characterized by an overworked thyroid gland. If my patient had hypothyroidism, I would prescribe her levothyroxine to address her condition.
- When we replace the thyroid hormone that has been depleted, the evidence suggests that we can alleviate many of the symptoms associated with hypothyroidism. Depending on the severity of her hyperthyroidism, she may require treatment with radioactive iodine or surgical intervention. Because of this, it is necessary to conduct long-term follow-ups on these individuals.
Question 5 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.
- In order to help balance the body’s metabolism, the medication’s mode of action involves supplying a replacement source of thyroid hormone. The starting dose is 25 mcg/day, which is marketed under the brand name Synthroid and is known by the generic name levothyroxine. The route is orally administered, and the frequency is once day. Levothyroxine is the medication of choice for the treatment of hypothyroidism.
- Levothyroxine is a synthetic hormone that is used to replace the amount of thyroid hormone that is deficient in the body’s tissues. In order for the medication to be effective, it must either replace or substitute for the thyroid hormone that is normally produced by the thyroid gland. The following are the FDA-approved doses, trade names, and generic names:
- Dose: In order to attain a serum TSH concentration between 0.5 and 2.0 mIU/LT, an initial dose of 12.5 mcg/day should be used. Levothroid, Levoxyl, Synthroid, Tirosint, Unithroid are some of the brand names. Levothyroxine sodium is the generic name for this medication. Oral communication is the preferred method. Once a day is the recommended frequency.
Question 6 What are the adverse effects, and what important teaching will you provide this patient on thyroid replacement therapy?
- Anxiety, arrhythmia, chest pain, diarrhea, dry mouth, headache, insomnia, joint pain, menstruation irregularities, nausea, and vomiting are just a few of the side effects that can occur as a result of thyroid replacement medication. Skin rash and itching, as well as weight loss or gain, are among the other side effects.
- Teachings regarding thyroid replacement therapy that will be provided to the patient include the fact that thyroid hormone should not be administered for at least 1 hour before or 2 hours after meals. Any missed doses that are remembered within 12 hours should be taken as soon as possible after they are missed.
- The missing dose should be skipped if it has been more than 12 hours since the missed dose was taken, and the next scheduled dose should be taken instead. Also instruct this patient to take their thyroid supplement at evening on an empty stomach in order to avoid food-drug interactions and to aid them in sleeping through any first adverse effects that may occur.
Gordon, S. (2021). Prednisone side effects: what to be aware of. Drugs.
Golder, S., Bach, M., O’Connor, K., Gross, R., Hennessy, S., & Hernandez, G. G. (2021). Public perspectives on anti-diabetic drugs: Exploratory analysis of Twitter posts. JMIR diabetes, 6(1), e24681.