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discussion

Peer Response

Instructions:

Review the plans posted by your peers from your advanced practice nursing role perspective (educator, leader or nurse practitioner). 

From this mindset, reflect upon a discussion you would like to have with your colleagues about their plan.

· For example – if you are a nurse educator (clinical or academic) what are your thoughts about the patient education provided in the plan, or do you want to comment on or add to the education provided?  

· If you a nurse leader what are your thoughts about the risk profile or cost effectiveness of the plan.? If you are a nurse practitioner did your peer develop a plan that aligns with evidence-based practice and current clinical guidelines? Etc.

Please be sure to validate your opinions and ideas with citations and references in APA format. 


Markel S. Dunn, PMH-RN

Jul 23 9:38pm| Last reply Jul 25 9:17am

Reply from Markel S. Dunn, PMH-RN

The patient is a 64-Year-old Hispanic male presenting with signs of Diabetes Mellitus Type II (DM2) and suboptimal blood glucose control, which is evidenced by current HbA1 7.8% and fasting blood glucose (capillary) of 150-190 mg/dl consistently (Arcangelo et al., 2022).  The patient also reports some burning sensations in his feet which could point to early peripheral neuropathy, despite normal monofilament testing.

Diagnosis:

-Type II Diabetes Mellitus

Management:

-The patient’s suboptimal glycemic control indicate that the current treatment regimen is ineffective and needs to be modified to improve blood sugar control overall.  The patient has managed to incorporate physical activity into his daily routine consisting of walks three to five times weekly and should be continued.

-A GLP-1 receptor agonist medication should be added to boost the effectiveness of the current Metformin treatment, as GLP-1’s when added to current treatment regimen have shown to be effective in lowering A1c and providing cardiovascular benefits (ElSayed et al., 2023).

-The patient is currently on the maximum effective dose of Metformin for DM2, and should be continued based on Metformin’s effectiveness when used with an added GLP-1 medication (Melenovský et al., 2024).

-Sulfonylurea medications such as Glipizide can contribute to weight gain, and should be discontinued being that the patient is at a healthy BMI, and the treatment has not been effective to date.

Prescriptions:

-Continue Metformin 1000 mg, take one tablet by mouth twice daily, dispense 30 tablets with three refills (ElSayed et al., 2023)

-Discontinue Glipizide 5 mg daily

-Start Semaglutide 0.25 mg, inject subcutaneously once weekly for 4 weeks, then increase to 0.5 mg once weekly as tolerated. 
Administer on the same day every week (ElSayed et al., 2023)

Education:

-Educate on the purpose of DC Glipizide

-Education on the purpose and mechanism of action of GLP-1 medication

-Educate on portential side effects of GLP-1 medication

-Educate on signs and symptoms of hypoglycemia

-Educate on daily blood glucose monitoring

-Continue carbohydrate control in diet

-Continue physical activity 3-5 times a week at least 15 minutes daily

Follow up:

-4 week follow up to assess adherence to treatment plan and blood sugar control via blood glucose diary.  Refer to neurology if burning in feet persist.  Refer to endocrinology should blood sugar remain suboptimal.

References

Arcangelo, V. P., Kang, T. M., Wilbur, V., & Peterson, A. M. (2022). 
Pharmacotherapeutics for advanced practice: A practical approach. Wolters Kluwer.

ElSayed, N. A., Aleppo, G., Bannuru, R. R., Beverly, E. A., Bruemmer, D., Collins, B. S., Cusi, K., Darville, A., Das, S. R., Ekhlaspour, L., Fleming, T. K., Gaglia, J. L., Galindo, R. J., Gibbons, C. H., Giurini, J. M., Hassanein, M., Hilliard, M. E., Johnson, E. L., Khunti, K., … Gabbay, R. A. (2023). Introduction and methodology:standards of care in diabetes-2024. 
Diabetes Care, 
47(Supplement 1).

Melenovský, V., Hošková, E., Velebová, K., Veleba, J., A. Borlaug, B., Benes, J., Kuda, O., Čajka, T., Segeťová, M., Thieme, L., Kopecký Jr., J., Kopecký, Sr., J., Pelikánová, T., Haluzík, M., Hill, M., & Kahleová, H. (2024). 
Metformin Improves Glycemic Control and Postprandial Metabolism and Enhances Postprandial Glucagon-like Peptide 1 Secretion in Patients with Type 2 Diabetes and Heart Failure: A Randomized, Double-Blind, Placebo-Controlled Trial.

CS


Cori Studzinski

Jul 23 9:31pm

Reply from Cori Studzinski

This patient’s diabetes is not well controlled despite being on combination therapy. This patient is also doing a great job following lifestyle modifications necessary for someone with diabetes. He is exercising regularly and his weight is well controlled. In researching there is not a clear amount of carbs that are recommended per day, but he is on the lower side of the carb intake which also helps control diabetes. Despite all of the lifestyle choices, and the combination drug therapy this patient’s diabetes is still uncontrolled.  

According to Arcangelo (2021), the addition of a basal insulin could be very beneficial in treating this patient’s diabetes. I think it is worth keeping him on the metformin 1000 mg PO BID with a quantity of 60 pills and 2 refills, and glipizide 5 mg PO daily with a quantity of 30 pills and 2 refills. He should also start taking Insulin Glargine. According to Arcangelo (2021), dosing for basal insulin in someone with type 2 diabetes should be 0.1 to 0.2 unit/kg/day or a starting dose of 10 units daily. The prescription for this patient would be Insulin Glargine kwikpen 10 units subcutaneously at bedtime with 1 refills to start. Arcangelo (2021) also suggests a titration schedule where the dosing is increased by 2 units every 3 days until fasting glucose is at goal. This patient should follow that titration plan with a maximum injection of 38 units daily as this is 0.5 units/kg/day.  

I would like to prescribe this patient a continuous glucose monitor as long as it is covered by his insurance so that he can keep a closer eye on his blood sugar levels after starting the Insulin Glargine. This patient needs comprehensive teaching for injecting insulin and to make sure that he understands the titration plan. I would also like one of the nurses working in the clinic to call the patient weekly to make sure that he is still doing well and is following the instructions. This patient needs to be aware of what symptoms to watch for that could indicate hypoglycemia and how to treat hypoglycemia. He should call the clinic if he experiences hypoglycemia as well.  

This patient should follow up for a check up in 1 month with an A1c in 3 months to evaluate the effectiveness of the treatment. If the patient gets to the maximum dosing of 38 units daily without his diabetes being better controlled then reconsideration may need to be made and the patient may need to start insulin injections with meals as well.  

 

References: Arcangelo, V. P. Peterson, A. M. Wilbur, V. Kang, T. M. (2021) 
Pharmacotherapeutics for advanced practice. [eBook edition]. Wolters Kluwer Health.  

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