Managing Type 2 Diabetes

The NP sees a 74-year-old woman with a BMI=30 kg/m2 who has a 30-year history of type 2 diabetes, HTN, and dyslipidemia. Pertinent social history includes the following: a retired elementary school teacher who lives in a 1-story home with her spouse and adult child, nonsmoker, drinks approximately 2, 5 oz glasses of wine per month, and walks approximately 2 miles per day. Her current medications include telmisartan, HCTZ, rosuvastatin, metformin, semaglutide and canagliflozin at optimized doses, and current A1c=9.2%. Her current A1c= 9.2% and is at HTN and lipid goal. Prior mediations have included sitagliptin, with patient stating, “That medication did not help my sugar at all.” She states she is adherent to her medications and dietary advice. Her eGFR is within acceptable parameters and she is feeling well. Physical exams are unremarkable. 

Which of the following is the most appropriate next step? 

A. Advise that her A1c is at an age-acceptable level.  

B. Add post-meal sliding scale rapid acting insulin 

C. Prescribe basal and pre meal insulin. 

D. Add oral glipizide.  

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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 NP is seeing a 74-year-old woman with a BMI of 30 who has a 30-year history of type 2 diabetes, hypertension, and dyslipidemia. Pertinent social history includes the following: she is a retired elementary school teacher who lives in a one-story house with her spouse and adult child. She is a non-smoker, drinks approximately two 5-ounce glasses of wine per month, and walks approximately 2 miles per day. 

Her current meds include telmisartan, hydrochlorothiazide, rosuvastatin, metformin, semaglutide, and canagliflozin at optimized doses and current A1C is 9.2%. And she is at hypertension and dyslipidemia goals. Prior medications include sitagliptin, with the patient stating “that medication didn't help my blood sugar at all.” She states she's adherent to her medications and dietary advice. Her estimated GFR is within acceptable parameters and she is feeling well. 

Physical exam is unremarkable. Which of the following is the most appropriate next step?  

A: Advise that her A1C is at an age acceptable level. 

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

C: Prescribe basal and pre-meal insulin. 

D: Add oral glipizide.  

The correct answer is C: Prescribe basal and pre-meal insulin. Once again, it's important to go back to the path of physiology of the disease. 

I like to remind people when they're getting ready for boards, it's almost always pathophysiology for the win because it will lead you to the clinical presentation and then the appropriate intervention. Type 2 diabetes is one of insulin resistance coupled over time with pancreatic beta cell failure. What happens with this beta cell failure? Insulin release is reduced. Now you may hear people say the days of folks with type 2 diabetes developing beta cell failure is likely waning. 

But at the same time, this person has had disease for 30 years and has not been able to take advantage of some of the meds that we now know contribute to the preservation of beta cells. In any event, what we have here is a situation where, after literally decades of type 2 diabetes, she has a degree of beta cell failure, and that accounts for the fact that her glucose control is no longer in range. 

As I've said in other programs, you have to look at every single word in a question to make sure you get the point of the clinical presentation you've been given. She's adhering to therapy and therapeutic lifestyle interventions. If it says in the question she is adherent, she is adherent. No second guessing on that one. As you will note, she is currently on semaglutide, aka Ozempic®, a GLP-1 agonist that is a potent insulin releaser. 

She was also on a DPP-4 inhibitor that was the sitagliptin, another medication that enhances insulin release. So she has now officially failed two insulin releases. And yet without any other identifiable causes, her blood sugars are elevated. This, coupled with her many decades of disease, tells me her pancreatic beta cell function is no longer sufficient to release enough insulin to maintain a euglycemic state. 

What are the guidelines for adding insulin to type 2 diabetes therapy? One of the main reasons is just what we're seeing here. In older adult with decades of disease, who is now failing to achieve glycemic control with one or more insulin releases. And it needs to be said, the GLP-1 agonist. Something along the lines of, semaglutide or a GLP-1 agonist like tirzepatide. 

These are simply the most potent insulin releasing medications around. And if people can't release enough insulin on one of those drugs, then it really tells you the pancreatic beta cells are just not working properly anymore. I know this seems like a good deal of work to unpack when answering what looks like a fairly cut and dry question on next medication and type 2 diabetes, but these are all the points you have to consider when answering this or any other board question. 

Remember, you're now a prescriber that's an entirely different role than the one that you have played as an RN. With this is background information, let's take another look at the question. The NP is seeing a 74-year-old woman with a BMI of 30 who has a 30-year history of type 2 diabetes, hypertension, and dyslipidemia. Pertinent social history includes the following: she's a retired elementary school teacher who lives in a one-story home with her spouse and adult child.  

She is a non-smoker and drinks about two 5-ounce glasses of wine per month and walks about 2 miles every day. Her current meds include telmisartan, hydrochlorothiazide, rosuvastatin, metformin, semaglutide, and canagliflozin. So let me just take a little sidestep on this one for a moment and go over the different classes of medicine. 

Telmisartan, ARB. Hydrochlorothiazide, thiazide-like diuretic; rosuvastatin obviously a statin; metformin, insulin sensitizer; or semaglutide, GLP-1 agonists insulin releaser, canagliflozin, an SGLT-2 I and glucose offloader via the kidney, all at optimized doses. And our current A1C is 9.2%. She is at hypertension and dyslipidemia goals. Prior medications have included a sitagliptin, DPP-4 inhibitor, with the patient stating “that medication didn't help my sugar at all.” 

She states she’s adhering to her medication and dietary advice. Her estimated GFR is within normal limits and she is feeling well. Physical exam is unremarkable. Which of the following is the most appropriate next step? A: Advise her A1C is at an age acceptable level. This of course, is incorrect. She's an older adult with type 2 diabetes. 

It might underlie saying the word might be acceptable, particularly to avoid high hypoglycemia that is very dangerous in older adults. To have an agency parameter as high as 8%, but 9.2% is too high. B: Add post-meal sliding scale rapid-acting insulin. That, of course, is incorrect, but might seem appropriate if you're reflecting on your inpatient role as an RN. What you often see in the inpatient setting, and it's often referred to as sliding scale insulin, which it's actually correction insulin used in the acutely ill adult. 

In other words, this is used to correct an elevated blood sugar. So, let's say that, for example, you had a patient who with diabetes, who's 65 years old, hospitalized with pneumonia. They usually have wonderful glycemic control. But now because they've got pneumonia and the stress on the body, the blood sugars are all of a sudden way out of range. 

Sometimes what is referred to as sliding scale insulin is given. It shouldn't be called that. It should be called correction insulin. Long and short sliding scale insulin will never-repeat-never be the correct answer on the NP board. Got it folks? Yes. Never the correct answer. Why? Because particularly in the day-to-day, this is a reactive way of treating hypoglycemia. 

Will you allow the blood sugar to rise? Then chase it down with insulin? So, correction insulin to an acutely ill person perfectly acceptable needs to be monitored very carefully. But it is done. Acceptable day-to-day sliding scale or correction insulin is never correct. This is a reactive way of treating hypoglycemia. It is dangerous. Creating significant hypoglycemia risk, in addition to allowing the blood sugar to swing way, way, way high, creating a difficult situation for the body, the target organs of type 2 diabetes, such as the kidney, the brain, the heart, and the peripheral nervous system, will be excessively exposed to periods of hypoglycemia, which can accelerate diabetic target organ dysfunction. 

C: Prescribe basal and pre-meal insulin. This is of course the correct answer. She's been tried on two insulin releasing meds, a GLP-1 agonist and a DPP-4 inhibitor. And as I mentioned before, GLP-1 agonist is one of the most potent insulin releasers. Even with this, she's been unable to achieve glycemic control, with no particular worrisome changes in lifestyle med adherence or anything else along those lines. 

It seems like she's staying the course with what she has done with her type 2 diabetes. She's at a point in her disease where her pancreatic beta cells are likely not releasing sufficient insulin to maintain euglycemia, and therefore she is at a point where what she needs is insulin replacement therapy. As an aside, the addition of basal and pre-meal insulin needs to be done carefully to avoid hypoglycemia and with considerable amount of patient coaching. 

This is where certified diabetes educators prove to be worth their weight in gold. Because remember, we often think we're the nurse. We can do all the education. Yeah, yeah, we can do a lot of it. On the other hand, we don't have half hour long visits in our schedule as a general rule, like a CDE would. 

And we don't have the schedules to see patients that are often as open as a CDE is? So, this is where we want to involve a certified diabetes educator. And one thing to keep in mind if you're part of a larger health care system, the CDE might not be an RN, it might be a pharmacist, it might be a nutritionist. 

There are a number of different people who are educated as CDEs. D: Add oral glipizide. This is also incorrect, of course, because glyphosate is a sulfonylurea. It's an example of another insulin releaser. She has failed insulin release. Trying another one is not going to make any difference in her clinical outcome. Key takeaway: evaluation questions focus on the patient's response to care. 

This requires the NP determine if therapeutic intervention has been adequate or needs to be adjusted in order to answer these questions correctly. And these are up to one and five exam questions on the board's knowledge of the course of a given disease is critical.  

Voiceover: Thank you for listening to NP certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast, and for more NP resources, visit FHEA.com.