Module II: Diabetes/Endocrine Topic Discussion
Module II: Diabetes/Endocrine Topic Discussion
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.
- 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.
- 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.
