Medication management in T2DM

The NP sees  a 44-year-old male of African ancestry with a BMI=34 kg/m2 and recently diagnosed  type 2 diabetes mellitus. He works on a rotating shift in healthcare and reports eating irregularly. He was started on metformin therapy 4 months ago, is at maximum recommended dose, and states he is tolerating the medication well. His initial A1c was 9.8%, with today’s A1c=8.7%. eGFR is within acceptable parameters and he is feeling well, stating, 

“I was so thirsty and needed to urinate all the time before I started that pill”. Physical exam reveals extensive acanthosis nigricans.  He mentions that his health insurance. “Does not pay for all that much. I’m OK with paying for the pill I am taking now, but really cannot afford expensive medicines. “ Which of the following is the most appropriate next step?

A. Prescribe weekly injectable semaglutide. 

B. Adding post-meal sliding scale rapid acting insulin.

C. Add a daily dose of pioglitazone.

D. Add glipizide on days when his eating schedule is predictable. 
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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: The nurse practitioner sees a 44-year-old male of African ancestry who has a BMI of 34 and recently was diagnosed with type 2 diabetes. He works rotating shifts in healthcare and reports eating regularly. He was started on metformin therapy 4 months ago, is at maximum recommended dose, and tolerating the medicine well. His initial A1C was 9.8%. 

Today's A1C is 8.7%. Estimated GFR is within acceptable parameters, and he states feeling well. He reports, “I was so thirsty and needed to urinate all the time before I started that pill.” Physical exam reveals extensive acanthosis nigricans. He mentions that his health insurance "doesn't pay for all that much. I'm okay with paying for the pill I'm on now, but I really can't afford expensive medications.” 

Which of the following is the most appropriate next step?  

A: Prescribe weekly injectable semaglutide. 

B: Add post-meal sliding scale rapid acting insulin. 

C: Add a daily dose of pioglitazone. 

D: Add glipizide on days when his eating schedule is predictable. 

The correct answer is C: Add a daily dose of pioglitazone. Where should you start with this question? 

First, consider what kind of a question it is. Given that we have a patient with a diagnosis who was started on therapy, and now we're seeing that patient and following up, this is an evaluation question. If you'll recall, the evaluation questions on the board are looking specifically at response to care. And the goal of a question like this is to see whether or staying the course. 

In other words, continuing current therapy is adequate or whether therapy needs to be adjusted. There are a number of components of unpacking this clinical scenario. We have an adult who's on the younger side for type 2 diabetes, although not alarmingly young. And he also has two risk factors for this condition: African ancestry and obesity. As I've said in other program, you have to look at every single word in the question to make sure you get the point of what's being presented clinically.  

Here we're told he works rotating shifts and eats irregularly. Another part is that we're told on physical exam he has extensive acanthosis nigricans, a condition associated with hyperinsulinemia and that needs to be taken into consideration. 

What intervention will help with reducing his insulin resistance? Certainly metformin is a great drug for reducing insulin resistance, but there's also another medication class that helps to achieve that goal. I also need to mention increasing physical activity and weight loss are also helpful in insulin resistance reduction. But what we're really looking at here are the medications. Another factor, he says that his health insurance doesn't pay a lot towards medications. 

Having practiced for literally decades in a federally qualified health center, this is something I've dealt with on a daily basis, and we need to consider this when choosing an answer. And yes, questions like this will come up on boards. And I've got a few other questions like this in a podcast series where it's really clear that what one of the purposes of the question is that the person is uninsured or has health insurance with limited drug coverage, and they're looking for you to prescribe an effective but least costly option. 

A prescribing adage is that the worst medication for a patient to have is one that the patient doesn't take. And if paying for a medication is an issue, that is a major risk factor for medication non-adherence. I know this does seem to be a lot to consider when answering a question that looks actually, on the surface, fairly cut and dry on next step medications for type 2 diabetes. 

But you have to consider all of this when answering any board question. Of course, last but certainly not least, most med questions on boards are safety questions at their core. The ADA states that therapeutic regimens for patients with type 2 diabetes must be formulated to help avoid hypoglycemia. With hypoglycemia, there is increased risk for falls, accidents, and with generally a patient older than this particular person, more like people and their 60s, 70s and beyond-cerebrovascular and cardiovascular events.  

We're also told, just as a reminder, that he has a major risk for developing hypoglycemia with certain type 2 diabetes meds. And that's working rotating shifts with irregular eating pattern. Therefore, when choosing additional therapies, if needed, we need to avoid meds associated with hypoglycemic risk. That's key, and I just need to add this. I think all of us can identify with working rotating shifts and eating on an irregular basis. 

With all of that as background information. Let's take another look at the question. The NP is a 44-year-old male of African ancestry with a BMI of 34 and recently diagnosed type 2 diabetes. He works rotating shifts in healthcare and reports eating irregularly. He was started on metformin therapy 4 months ago, is at maximum recommended dose, and states he's tolerating the medication well. 

His initial A1C was 9.8%, with today's A1C at 8.7%. Estimated GFR is within acceptable parameters, and he's feeling well stating, “I was so thirsty and needed to urinate all the time before I started that pill.” Physical exam reveals acanthosis nigricans. He mentions that his health insurance "doesn't pay for much. I'm okay with paying for the pill I'm taking now, but I really can't afford expensive medications.” 

Which of the following is the most appropriate next step? A: Prescribe weekly injectable semaglutide. Semaglutide, brand name Ozempic, is a GLP-1 agonist-would also be a great option for this patient. It's going to help improve his glycemic control. Because clearly he does need more help with that. With this drug class is virtually no risk for hypoglycemia, as it helps enhance insulin release in response to hypoglycemia. 

An added bonus would be weight loss is usually seen with GLP-1 use, given his diagnosis of obesity. Unfortunately for all those wonderful things that I can say about the GLP-1 agonists as a group, this is a really expensive drug class and he clearly wants to avoid that expense. This is a perfect example of a question response that is technically correct, but it's not the best answer for the given situation. 

Option B: Adding post-meal sliding scale rapid acting insulin. This is also incorrect, and it's also type of question that a new grad NP might feel comfortable with. As you have likely seen, sliding scale insulin prescribing in the inpatient or the acute care setting. And indeed, when people talk about “sliding scale insulin,” what you're actually using is that correction insulin, in other words, added insulin being given to manage a temporary state of hypoglycemia in any event using post-meal insulin. 

What is mentioned here refers to the practice of allowing the blood sugar to rise and then chasing it down with some insulin. This is a reactive way to treat hypoglycemia that can result in marked increases and decreases in blood sugar. I can't say this strongly enough. The ADA has advocated for years that we discontinue the practice of post-meal sliding scale insulin. 

It is dangerous. It is associated with higher cardiovascular risk. Well, I think I've made my point on that one, but we should not be doing that. On occasion do we need to prescribe correction insulin for an acutely ill person who has temporary hypoglycemia? Yes, that's acceptable, but not every day. Post-meal sliding scale insulin. C: Add a daily dose of pioglitazone. 

This is the best answer. Pioglitazone acts as an insulin sensitizer or and has known cardiovascular benefits with minimum risk of hypoglycemia and at a reasonable cost. This drug has a different mechanism of action when compared to metformin and will help the patient utilize the insulin. He is likely producing pioglitazone and comes from the class of medications called TZD or thiazolidinediones. 

Indeed, typical A1C drop will be about 1 to 2% with its use. So that you can see he's in the high eights now. That'll bring his A1C down to maybe the high sevens, which of course he would still need more help with maintaining glycemic control, but it might even bring it down to the high sixes, which then he would be within the desired range of A1C of less than 7%. D: Add glipizide on days when his eating schedule is unpredictable. 

Well, one of the things about glipizide is it's a sulfonylurea. It's a cheap drug, but this is just not a wise answer. As you know, the use of a sulfonylurea or a medication that enhances insulin release regardless of blood glucose can be associated with hypoglycemia risk, particularly in people with irregular eating schedules. This patient needs improved glycemic control every day. 

Just not maybe, let's say on his days off when his eating schedule is more predictable. Key takeaway: one of the most important parts of the NP roles is being a safe and thoughtful prescriber. Understanding how medications modify a disease pathophysiology and considering social factors such as cost are critical to this practice. 

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