Diabetes and Endocrine System

Topic II: Endocrine Disorders
Introduction
Metformin is strongly associated with improved long-term outcomes for adults with Diabetes Type 2, and should almost always be initiated first and maximized prior to initiating other drug therapies.
There are multiple options for which drugs to initiate after metformin, including other oral agents (sulfonylureas, thiazolidinediones, alpha-glucosidase inhibitors, meglitinide analogs, DPP-4 inhibitors, SGLT2 inhibitors) as well as injectable agents (GLP1 agonists/incretin mimetics and pramlintide, as well as Insulin).
Insulin in conjunction with Metformin should be considered as initial therapy for patients with very high HgbA1C values (> 9%) at diagnosis (usually basal insulin is the first insulin added), especially if the patient is symptomatic. Other dual or triple therapy may also be considered with high initial HgbA1C.
Patients with diabetes qualify for adjunctive treatment with an ACE inhibitor, statin, and aspirin regardless of comorbid diagnoses. For those with comorbid HTN or CAD, choices of therapies for those conditions should be re-evaluated and brought in line with recommendations for diabetes care if possible (other antihypertensive changed to ACE inhibitor for instance).
Newer diabetes medications (especially DPP-4 inhibitors, SGLT2 inhibitors, GLP1 agonists/incretin mimetics and pramlintide) which mechanistically interesting, lack evidence for improving morbidity and mortality outcomes; with some exceptions. As they can help lower HgbA1C, they may be most clinically useful in situations where they can be exploited for their side effect profiles (such as weight loss) or in patients who have had limited effectiveness on other agents and combinations. These newer agents are often associated with high costs to the patient (regardless of insurance coverage - as they are usually a less preferred agent via the insurance as well as very costly agents anyhow).
Insulin should not be seen as an agent "of last resort", but rather as an effective means of reaching glycemic targets. Insulin may be a reasonable second or first line therapy for patients, and patients should be counseled that this does not constitute a failure of medical or lifestyle interventions. A basal-bolus approach with rapid(or short acting) and very long acting insulins is preferred, but mixed insulin and intermediate acting insulin (e.g. 70/30) may be obtained for reasonable prices and utilized in cases where cost is an issue.
Treatment of conditions such as depression, obesity, or "symptoms" with levothyroxine in the face of normal thyroid function testing is not supported by data.
Dietary supplements/nutraceuticals to treat thyroid problems (including iodine supplements and selenium supplements) are not recommended.
Diabetes is one of the largest threats to both individual and public health in America today.
While Diabetes Type 1 and Type 2 begin as distinct pathologies (Type 1 as an autoimmune mediated disorder and Type 2 mainly as a response to environmental challenges such as obesity) people with longstanding disease of either type are at risk for complications. Most patients with Type 2 disease will follow a progressive course which results in an almost complete lack of insulin activity and secretion - necessitating the use of exogenous insulin therapy. Because diabetes poses such strong risks to cardiovascular and renal health, adjunctive therapy with a statin, and ACE inhibitor (or ARB), and aspirin should be considered for every diabetes patient.
Please review the treatment algorithms available from both the ADA and the AACE guidelines. Note similarities and differences.
American Diabetes Association: ACCE /ACE:
Hypothyroidism is effectively treated with any medication that supplies levothyroxine. Patient should be monitored if switching between different brands (or brand/generics) of levothyroxine therapy - although there is no evidence that one brand of medication (or generic versus brand) is superior for treatment.
Most adult patients may be started on the full replacement dose of levothyroxine (~75-125 mcg/day) without problems. However, patients with cardiac concerns or elderly patients may benefit from starting on a lower dose (~12.5-50 mcg/day) and titrated as tolerated.
There is no evidence for benefit of either adding a T3 preparation (triiodothyronine / liothyronine) or utilizing a whole thyroid preparation in conjunction with or in place of levothyroxine. There are potential toxicities associated with some of these products as well as additional side effects (without additional benefit to the patient).
Objectives
At the completion of this module the student will be able to:
recommend the appropriate medication regimen for a newly diagnosed patient with diabetes.
suggest modifications to a medication regimen for diabetes in a patient with suboptimal glycemic control or adverse effects.
recommend the appropriate titration of insulin (types and amounts) in a patient with suboptimal glycemic control or adverse effects.
recognize the appropriate adjunctive medications that should accompany treatment for diabetes (statin, aspirin, ACE inhibitor) and suggest modifications to other regimens to comply with these standards.
recommend appropriate medication and dosing for thyroid replacement therapy.
recommend appropriate titration of levothyroxine based on thyroid function testing.
Readings
Pharmacotherapy Principles and Practice
Chapter 43 Diabetes
Chapter 44 Thyroid Disorders
Other Resources
Diabetes
Dynamed Summary for Diabetes Type 1: https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T116244/
Dynamed summary for Diabetes Type 2 in adults: https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T113993/
Glucose lowering medications for type 2 diabetes: https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T115979/
Insulin for type 2 diabetes with suboptimal glycemic control: https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T360975/
Thyroid disorders
Dynamed summary for Hypothyroidism in adults: https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T115914/
Dynamed summary for Hyperthyroidism and thyrotoxicosis in adults: https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T116479/
Videos
Thyroid Function and Hormones: https://www(dot)youtube(dot)com/watch?v=uCjpGlnCjeA
Transcript for Thyroid Hormone Synthesis video
Insulin Types and Activity: https://www(dot)youtube(dot)com/watch?v=ZN1SDz17Y-M
Transcript for Insulin Types and Activity video
Diabetes Medications: https://www(dot)youtube(dot)com/watch?v=FPddG1w9luo
Transcript for Diabetes Type 2 Medications video
Module II Discussions & Assignments
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)
What additional medications, other than those for glucose control, should be included in a comprehensive pharmacotherapeutic plan and why? [See textbook secions on Treatment of Concomitant Conditions]
Now let’s consider the following case about thyroid disorders. A 69-year-old man goes to his family doctor because he has been feeling fatigued and lethargic. His doctor does a complete evaluation. This patient had a myocardial infarction and has a recurrent ventricular arrhythmia (treated with amiodarone). The patient’s TSH is elevated and his T4 is slightly decreased.
Please provide an evaluation of this patient’s condition, approach to therapy and factors you have taken into consideration
Module II: Diabetes/Endocrine Topic Discussion
Assignments

None

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.
Special Guidance on APA formatting in Discussion Posts
APA formatting is required in discussion posts with the following two exceptions (due to limitations with the text editor in LIVE): double line space and indent 1/2 inch from the left margin. Discussion posts will NOT be evaluated on those two formatting requirements. All other APA formatting guidelines should be followed. For example, in-text citations must be formatted with the appropriate information and in the correct sequence (Author, year), reference list entries must include all appropriate information following guidelines for capitalization, italics, and be in the correct sequence. Refer to the APA Publication Manual 7th ed. for each source type's specific requirements. Please let your instructor know if you have any questions.