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NSG-533 Diabetes/Endocrine Topic Discussion
NSG-533 Diabetes/Endocrine Topic Discussion
Module II: Diabetes/Endocrine Topic Discussion
Must post first.
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.  

Is it okay to start a patient on a drug (particularly an oral drug) other than metformin as an initial drug?  Please cite possible circumstances where this could be reasonable.
What anti-diabetic medications have compelling evidence for use in select populations, possibly as initial therapy, and is this benefit a “class” effect?

(eg. SGLT2Is – Patients with type 2 diabetes and a high risk of cardiovascular disease had reduced risk of a cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke relative to those randomized to receive placebo)

How can patients and practitioners be convinced to change their behavior and opt for more evidence based approach to therapy?

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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Discussion 2
Dianne Cohen posted Sep 9, 2020 7:58 PM
   Diabetes mellitus is one of the largest epidemics the world has faced and according to the International Diabetes Federation (IDF), in 2015 there were 415 million people affected by the disease (Zimmet et al., 2016). The four types of diabetes include; Type 1 diabetes accounting for 5-10% of all diabetic patients and is due to autoimmune B-cell destruction, type 2 accounting for 90-95% of all diabetes and is due to a progressive loss of adequate B-cell insulin secretion, gestational diabetes diagnosed during pregnancy, and diabetes due to other medical conditions (ADA, 2020). For patients with a contraindication, according to Flory and Lipska, sodium-glucose co-transporter 2 (SGLT-2 inhibitors) such as Jardiance and glucagon-like peptide 1 receptor agonists (GLP-1) such as Trulicity could be considered (2019). Their use is supported by clinical trials of thousands of patients in the modern context of antiplatelet, statin, and blood pressure management. However, newer drugs have primarily been studied as add-on therapy to metformin in patients with cardiovascular disease ( Flory and Lipska, 2019). Another important option for patients who can not take metformin is sulfonylureas (SUs/glinides) such as Glucotrol and Diabeta due to there cost-effective nature. However, they are also contraindicated in patients with acute liver injury and CKD (Flory and Lipska, 2019). There is not a consensus on which agents to use when metformin is not acceptable, and an individualized approach is recommended (ADA, 2020). At the same time, the American Association of Clinical Endocrinologists (AACE) lists non-metformin preferences in order with GLP-1 RAs listed first and dipeptidyl peptidase 4 (DPP-4 inhibitors) as the second, for monotherapy (Goldman-Levine, 2015, p.689). In addition, the use of metformin in hospitalized patients is controversial and historically patients are managed using a sliding scale insulin regimen which has no proven benefit (Kodner et al., 2017) NSG-533 Diabetes/Endocrine Topic Discussion. Its continued use during hospitalization is primarily due to dietary changes, medication changes, and acute illness which all worsen hyperglycemia (Kodner et al., 2017).  In conclusion, there is an array of medications for treating diabetes, however, metformin’s robust safety data appears to give it an advantage over other medications. In the absence of any contraindications, is the primary care provider always justified in its selection?                                                             ReferencesCowie, C. C. (2019). Diabetes diagnosis and control: Missed opportunities to improve health. Diabetes Care, 42(6), 994-1004. doi:10.2337/dci18-0047  
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Last post Sep 19, 2020 11:19 PM by Dianne Cohen
Zimmet, P., Alberti, K. G., Magliano, D. J., & Bennett, P. H. (2016). Diabetes mellitus statistics on prevalence and mortality: Facts and fallacies. Nature Reviews.Endocrinology, 12(10), 616-622. doi:http://dx.doi.org.wilkes.idm.oclc.org/10.1038/nrendo.2016.105
Kodner, C., Anderson, L., & Pohlgeers, K. (2017). Glucose Management in Hospitalized Patients. American Family Physician, 96(10), 648–654.
Flory, J., & Lipska, K. (2019). Metformin in 2019. JAMA: Journal of the American Medical Association, 321(19), 1926–1927. https://doi-org.wilkes.idm.oclc.org/10.1001/jama.2019.3805
Goldman-Levine, J., (2015). Combination Therapy When Metformin is Not an Option for Type 2 Diabetes. Annals of Pharmacotherapy, 49(6), 688-699. https://doi-org.wilkes.idm.oclc.org/10.1177%2F1060028015572653
American Diabetes Association. (2020). Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes, 43(Supplement 1): S14-S31. https://doi.org/10.2337/dc19-S002

Clearly, it is incumbent upon the primary care provider to use the latest evidence-based research from reputable and credentialed associations such as the ADA and the AACE when deciding which medication is best for their patient NSG-533 Diabetes/Endocrine Topic Discussion. Additionally, it requires a thorough discussion with the patient and also taking into account the patient’s medical history, lifestyle, and finances.
Disproportionately, patients with chronic hyperglycemia are at risk of developing serious complications such as heart disease, blindness, limb amputations, and kidney failure due to microvascular damage (Zimmet et al., 2016). Fortunately, with prompt treatment, and screenings such as fasting plasma glucose (FPG) and a glycated hemoglobin test (A1C), primary care providers can detect and slow the progression of diabetes. (Cowie, 2019). With unlimited access to information, patients will sometimes self diagnose and request a medication based on a popular television commercial. Not quite as well known to patients but having a long track record is metformin also known as Glucophage to many. According to Flory and Lipska, metformin is the first-line pharmacologic treatment for type 2 diabetes and the most commonly prescribed drug for this condition worldwide due to its numerous studies and randomized clinical trials (2019). However, metformin can cause serious gastrointestinal disturbances and is not recommended in all patients especially those with chronic kidney disease (CKD), acute heart failure, and hepatic failure ( Flory and Lipska, 2019). Particularly, according to Goldman-Levine, metformin should be discontinued in patients with a glomerular filtration rate (eGFR)  less than 30 mL/min (2015).
Module Two- Tomiko Edmonds
Tomiko Edmonds posted Sep 9, 2020 10:00 PM
Recent data indicates that 85.6% of adults with diagnosed diabetes are treated with Diabetes medication. Results from the National Health and Nutrition Examination Survey (NHANES) indicate that only about 50% of American adults with Diabetes are achieving HbA1c <7.0% (<53 mmol/mol) (Edelman & Polonsky, 2017). Modern day medicine and guidelines from the American Diabetes Association (ADA) have spent an enormous amount of time and resources to prove that certain classes of medications are best served to treat diabetes NSG-533 Diabetes/Endocrine Topic Discussion. It is argued that therapeutic interventions that target hyperglycemia but do not correct the underlying pathogenic disturbances are unlikely to result in a sustained benefit on the disease process, (Abdul-Ghani & DeFronzo, 2017).Metformin has been found to have additional benefits in its use. The addition of Metformin for patients with type 2 diabetes and a high risk of cardiovascular disease had reduced risk of a cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke relative to those randomized to receive placebo (Edelman & Polonsky, 2017). The use of SGLT2Is is now widely acceptable as a successful therapy to treat. For the first time, SGLT2 inhibitors offer a therapeutic approach acting directly on the kidneys without requiring insulin secretion or action, (Seufert, 2015).Diabetes, especially Type II Diabetes is a hot topic in my household as well as in my daily practice. I myself was diagnosed with type II Diabetes some years ago while pregnant. Over the course of several years, I was trialed on several therapies until I landed on the treatment that truly worked for me and this treatment, did not include medication therapy at all.                                                                                                                 ReferencesEdelman, S. V., & Polonsky, W. H. (2017). Type 2 diabetes in the real world: The elusive nature of glycemic control. Diabetes Care, 40(11), 1425–1432. https://doi.org/10.2337/dc16-1974Seufert, J. (2015). Sglt2 inhibitors – an insulin-independent therapeutic approach for treatment of type 2 diabetes: Focus on canagliflozin. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 543. https://doi.org/10.2147/dmso.s90662
Pharmacologic approaches to glycemic treatment: Standards of medical care in diabetes—2019. (2018). Diabetes Care, 42(Supplement 1), S90–S102. https://doi.org/10.2337/dc19-s009
Abdul-Ghani, M., & DeFronzo, R. A. (2017). Is it time to change the type 2 diabetes treatment paradigm? yes! glp-1 ras should replace metformin in the type 2 diabetes     algorithm. Diabetes Care, 40(8), 1121–1127. https://doi.org/10.2337/dc16-2368 NSG-533 Diabetes/Endocrine Topic Discussion.

The rate of compliance for a medication is directly correlated on the understanding of its use as well as the access to the medication at hand. Each practitioner and patient must be open to educating themselves on the risks versus the benefits of the medication as well as reading multiple, evidenced based studies that have been completed. These studies should not have been sponsored by organizations that have a stake in monetary gain. Patients need to understand that the medication they are taking is used for their benefit and must not cause additional harm to their physical being nor their finances.
Metformin is effective and safe, is inexpensive, and may reduce risk of cardiovascular events and death, (“Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2019,” 2018). While Metformin is an effective first line drug that offers several benefits such as cardiovascular protection, it lacks any effect on β-cell function, which is the primary pathophysiological disturbance responsible for progressive hyperglycemia in T2D patients, (Abdul-Ghani & DeFronzo, 2017). Medication and lifestyle changes should be introduced prior to adding a concomitant therapy. If this prescribed regimen is not successful, then other therapies may be introduced.  Studies on additional treatments have now been done to get to the root cause of the issue which is hyperglycemia NSG-533 Diabetes/Endocrine Topic Discussion.
Module 2-Karen Halter
Karen Halter posted Sep 8, 2020 9:22 PM
Pharm Module 2 discussion Karen HalterFor patients unable to take metformin due to poor renal function, I would discuss the use of meglitinides in conjunction with low dose sulfonylureas. Taylor reports “The meglitinides have short half lives and relatively low rates of hypoglycemia. Repaglinide is hepatically metabolized to inactive metabolites and thus can safely be used in patients with renal insufficiency.” (Diabetes Medications in Renal Insufficiency, 2010) I feel careful renal monitoring and lower dose of a sulfonylurea would have a more protected outcome for renal function. Carlson, J. S. (2019). Type 2 diabetes therapies: A steps approach. American Family Physician. https://www.aafp.org/afp/2019/0215/p237.htmlDiabetes medications in renal insufficiency. (2010). Endochrinetoday. https://www.healio.com/news/endocrinology/20120325/diabetes-medications-in-renal-insufficiency
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Last post Sep 18, 2020 9:19 AM by Kelly Miskovsky
Chisholm-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 NSG-533 Diabetes/Endocrine Topic Discussion.


As always, as prescribers we should always follow the evidence based approach-which currently is metformin, if not contraindicated and tolerated. I would also discuss at length lifestyle changes and non-pharmaceutical interventions like exercise, nutrition, and weight management.
The prevalence of diabetes in the United States is staggering. For newly diagnosed patients with Type 2 DM, metformin is considered the gold standard of therapy.(Chisholm-burns et al., 2019, p. 668) In an article in American Family Physician it was noted that metformin was still the number one drug of choice in initial therapy for Type2DM, utilizing the STEPS (safely, tolerability, effectiveness, price and simplicity).(Carlson, 2019) Metformin is contraindicated in patients with poor renal function (eGFR<30-45). (Chisholm-burns et al., 2019, p. 670)
Diabetes First Line Discussion
Jessica Faltinowski posted Sep 9, 2020 2:10 PM
Diabetes Medication DiscussionThe goal of pharmacological interventions with diabetes is to decrease the blood sugar and the glycosylated hemoglobin, more commonly referred to as HbA1c or simply A1c.  An A1c of 5.7-6.4% indicates pre-diabetes and an A1c of 6.5% and greater by two separate tests is a confirmation of the diagnosis of diabetes type 2 (“2. Classification and Diagnosis of Diabetes,” 2014).  Initially a patient is encouraged to manage their diabetes through lifestyle modification, which is effective for some patients.  However, many patients find that this is not enough and need to begin medication.As many of these medications are relatively new, they are also much more expensive than metformin or second-generation sulfonylureas.  A practitioner needs to carefully analyze the risks versus benefits and review The American Diabetes Association’s (ADA) recommendations.  Metformin continues to be the most effective and least expensive medication to manage type 2 diabetes.  Metformin also has one of the lowest incidences of side effects.  Many patients see commercials on television for new diabetes medications and request them from their providers.  However, these patients are not generally aware of ADA recommendations, nor the cost of these medications.  Many are not covered by commercial drug plans or Medicare as they do not meet the recommendations.  All these factors must be taken into consideration as one prescribes medication.2. classification and diagnosis of diabetes. (2014). Diabetes Care, 38(Supplement_1), S8–S16. https://doi.org/10.2337/dc15-s005Hsia, D. S., Grove, O., & Cefalu, W. T. (2016). An update on sodium-glucose co-transporter-2 inhibitors for the treatment of diabetes mellitus. Current Opinion in Endocrinology & Diabetes and Obesity, 1. https://doi.org/10.1097/med.0000000000000311Kim, K.-S., Lee, B.-W., Kim, Y., Lee, D., Cha, B.-S., & Park, C.-Y. (2019). Nonalcoholic fatty liver disease and diabetes: Part ii: Treatment. Diabetes & Metabolism Journal, 43(2), 127. https://doi.org/10.4093/dmj.2019.0034Maruthur, N. M., Tseng, E., Hutfless, S., Wilson, L. M., Suarez-Cuervo, C., Berger, Z., Chu, Y., Iyoha, E., Segal, J. B., & Bolen, S. (2016). Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes. Annals of Internal Medicine, 164(11), 740. https://doi.org/10.7326/m15-2650

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View profile card for Kelly Miskovsky
Last post Sep 18, 2020 9:16 AM by Kelly Miskovsky
Marín-Peñalver, J., Martín-Timón, I., Sevillano-Collantes, C., & Cañizo-Gómez, F. (2016). Update on the treatment of type 2 diabetes mellitus. World Journal of Diabetes, 7(17), 354. https://doi.org/10.4239/wjd.v7.i17.354
Jia, Y., Lao, Y., Zhu, H., Li, N., & Leung, S. (2018). Is metformin still the most efficacious first‐line oral hypoglycaemic drug in treating type 2 diabetes? a network meta‐analysis of randomized controlled trials. Obesity Reviews, 20(1), 1–12. https://doi.org/10.1111/obr.12753
Aroda, V. R., & Ratner, R. E. (2018). Metformin and type 2 diabetes prevention. Diabetes Spectrum, 31(4), 336–342. https://doi.org/10.2337/ds18-0020


Evidence-based guidelines recommend metformin, a biguanide, as first-line monotherapy in diabetes type 2 (Jia et al., 2018).   According to Maruthur, metformin “inhibits hepatic gluconeogenesis through activation of adenosine monophosphate-activated protein kinases and induces glucose uptake into muscle cells” (2016, p. 9).  Simply put, metformin decreases inhibition of the enzyme that converts glycerol to glucose and increases insulin sensitivity.  However, like all medications, it is not without risk and is contraindicated in certain patient populations.  The use of metformin increases the risk of lactic acidosis and should not be used by patients with liver disease, including fatty liver disease or cirrhosis, or in patients with renal insufficiency (Aroda & Ratner, 2018). These patients should instead be started on a different initial medication.  The current recommendation for patients that concurrently have type 2 diabetes and nonalcoholic liver disease is pioglitazone (Kim et al., 2019).  Unfortunately, there are many unpleasant risks and side-effects with this medication such as weight gain, heart failure, myalgia, and an increased risk of upper respiratory infections and bladder cancer.  Patients who have cardiovascular disease or who are high risk for it, may benefit instead from a sodium-glucose co transporter-2 (SGLT2), as this latest class of approved medications for type 2 diabetes has cardioprotective factors and also can still be used while using a beta blocker such as metoprolol (Hsia et al., 2016).
The rise of diabetes mellitus (DM) type 2 has become a worldwide health crisis, affecting more than 400 million people (Marín-Peñalver et al., 2016).  Unlike type 1 diabetes mellitus, an autoimmune disorder, in which those affected do not produce sufficient insulin related to pancreatic beta cell destruction, the cause of type 2 diabetes has a significantly different pathology.  Type 2 diabetes is a chronic disease, thus more commonly seen as people age.  In this disorder, glucose is not taken into the cells and instead stays in the bloodstream causing hyperglycemia.  This disorder is often a combination of lifestyle and genetics.  Some patients have a genetic predisposition for type 2 diabetes; however, lifestyle contributes highly to not only the disorder, but also to its manageability.  Those who are obese or overweight, physically inactive, have hypertension, or a poor diet are much more likely to develop type 2 diabetes (Maruthur et al., 2016).
Discussion 2
Carlita Lockett posted Sep 6, 2020 11:45 PM
In the nursing profession, most of our patients that we work with have diabetes or will develop diabetes during the time we know them. It is important that when prescribing medications that the nurse practitioner is aware of the pros and cons that go with the older medications to treat diabetes, as well, as the newer medications. Patients who have kidney and liver issues would be one of the groups of patients who shouldn’t use Metformin. Metformin has few adverse side effects, the most common adverse side effects being gastrointestinal symptoms (incidence rate 20-30%), including nausea and vomiting, and the most serious adverse effects being lactic acidosis (incidence rate 1/30,000), mainly in diabetic patients with liver and kidney dysfunction (Cheng et al, 2017) NSG-533 Diabetes/Endocrine Topic Discussion.
Although many prescribers choose to use Metformin as an initial drug for diabetes, patients can be prescribed Farxiga and Jardiance. These two drugs specifically benefit the populations that have diabetes and complications of either atherosclerotic or cardiovascular disease and individuals who have kidney disease. These benefits could be listed as a “class” effect. Farxiga can be used in patients with atherosclerotic or cardiovascular disease and Jardiance can be used for individuals who have kidney disease. Based on a total of 145 events, dapagliflozin did not increase the hazard ratio (0.82; 95% CI 0.58 to 1.15) for the composite cardiovascular endpoint (defined as time to the first event of cardiovascular death, myocardial infarction, stroke, or hospitalization for unstable angina) compared with control arms (Bekiari et al., 2015).
Patients and practitioners may find difficulty in choosing one of the newer anti-diabetic drugs for initial therapies because Metformin has been used for so long and proven to be effective. Throughout the education process, it could be introduced that conducting our own research using evidence-based data prior to practicing is acceptable and expected. We could also rely on evidence-based data upon completion of our degree in order to make sure we are providing the best treatment to our patients with the highest efficacy. As a patient, we need to be comfortable with challenging our providers and gathering our own information regarding which medications best suit us and our medical history. Practitioners and educators need to promote our patients to do research prior to beginning a new medication and asking specific questions.  This level of acceptance will help promote the use of evidence-based data to help patients and practitioners to make the best informed decisions.         with type 2 diabetes mellitus. Therapeutic advances in endocrinology and metabolism, 6(2), 61-67.Cheng, J., Feng, X., He, S., Huang, Luo, Y., Q., Tian, L., & Wang, Y. (2017). Metformin: A review of its potential indications. Drug design,       https://doi.org/10.2147/DDDT.S141675
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Last post Sep 13, 2020 11:04 PM by Tomiko Edmonds
       development, and therapy, 11, 2421-2429.
Bekiari, E., Boura, P., Liakos, A., Karagiannis, T., & Tsapas, A. (2015). Update on long-term efficacy and safety of dapagliflozin in patients
Module 2 Discussion
Augusta Ibeh posted Sep 9, 2020 4:48 AM
            Type 2 diabetes mellitus (DM) is a chronic metabolic disorder in which prevalence has been increasing steadily all over the world Olokoba, Obateru, & Olokoba (2012). Type 2 DM is usually as a result of lifestyle factors (lack of exercise, eating habit, choice of food) and genetic. Overweight has been the main influence on type 2 DM.

Glycemic goals should be individualized based on patient characteristics.
Antidiabetic treatment should be promptly intensified to maintain blood glucose at individual targets.
Combination therapy will be necessary for most patients.
Selection of agents should be based on individual patient medical history, behaviors, and risk factors, and environment.
Insulin is eventually necessary for many patients.

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 I

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