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RJ: client living with type 2 DM, Treatment of Type 2 Diabetes (Metformin,…

- - - - Management of type 1 or 2 diabetes mellitus or pre-diabetes.
    - - Decreases hepatic glucose production
        
        Maintenance of blood glucose and improved blood glucose control.
      - Decreases intestinal glucose absorption
      - Increases insulin sensitivity
    - - Absorption
        
        50-60% absorbed following first-pass metabolism
      - Distribution
        
        Widely distributed throughout the body. Enters breast milk.
      - Metabolism and excretion
        
        Eliminated mostly unchanged by the kidneys
      - Half-life
        
        17.6 hours
    - - PO-ER
        
        Peak
        
        4-8 hr
        
        Duration
        
        24 hr
        
        Onset
        
        Unknown
      - PO-IR
        
        Peak
        
        Unknown
        
        Duration
        
        12 hr
        
        Onset
        
        Unknown
    - - Severe renal impairment (CCr <30 mL/min)
      - Iodinated contrast imaging in clients with CCr 30-60 mL/min, hx liver disease, or hx alcoholism
      - Metabolic acidosis (including DKA)
      - Hepatic impairment
      - Hypersensitivity
    - - OB/Lactation/Pedi
        
        use with caution when pregnant or breastfeeding; metformin enters breast milk
        
        Extended release options best for use in clients under 17 years of age.
      - Older Adults
        
        May be at increased risk of lactic acidosis
      - Hypoxic States: Acute HF, shock, MI, sepsis
      - Surgery (Metformin should be discontinued when food and/or liquid is restricted pre-surgery)
      - Alcoholism
      - Pituitary deficiency or hyperthyroidism
      - Mild to moderate renal impairment (CCr 30-60 mL/min).
    - - GI
        
        Diarrhea
        
        Nausea
        
        Abdominal bloating
        
        Vomiting
      - Fluid and Electrolytes
        
        Lactic Acidosis
      - Hematological
        
        Decreased vitamin B12 levels
    - - Drug-Drug
        
        Acute or chronic alcohol consumption
        
        Digoxin
        
        Calcium Channel Blockers
        
        Furosemide
        
        Morphine
      - Drug-Natural Products
        
        Glucosamine
        
        Chromium and coenzyme Q-10
  - - - Primary prevention of CAD (MI, stroke, angina) in asymptomatic clients with high LDLs and decreased HDLs.
      - Adjunct management of primary hypercholesterolemia and mixed dyslipidemia.
    - - Inhibits 3-hydroxy-3-methylglutaryl-conenzyme A (HMG-CoA) reductase , an enzyme responsible for catalyzing an early step in the synthesis of cholesterol.
      - Lowers total LDLs and triglycerides. Slightly increased HDLs.
        
        Reduces likelihood of MI and stroke
    - - Metabolism and Excretion
        
        Heavily broken down by the liver, most during first-pass metabolism. Under 2% of Atorvastatin is excreted by the kidneys unchanged.
      - Half-life
        
        14 hrs. 2 lipid-lowering metabolites of Atorvastatin can be present in the body up to 20-30 hrs, elongating its therapeutic effect.
      - Distribution
        
        Widely distributed. Enters breast milk.
      - Absorption
        
        Rapid absorption but undergoes extensive GI and hepatic metabolism resulting in ~14% bioavailability.
    - - PO
        
        Onset
        
        Unknown
        
        Peak
        
        Unknown
        
        Duration
        
        20-30 hrs
    - - Hypersensitivity
      - Active liver disease and/or chronic elevation in AST and ALT
      - Atorvastatin is contraindicated in pregnancy and in breast feeding as it may result in harm to the fetus (due to its altering of cholesterol levels).
    - - Women who intend to become pregnant or who have a high likelihood of becoming preganant
      - Children under 10 years of age (little research to support safe use)
      - Uncontrolled hypothyroidism or renal impairment
      - Increased risk of myopathy
      - Alcoholism
      - Hx Liver Disease
    - - Respiratory
        
        Bronchitis
      - Neurological
        
        Amnesia, confusion, dizziness, headache, insomnia, memory loss, weakness.
      - Hypersensitivity
      - Musculoskeletal
        
        Rhabdomyolysis, arthritis, immune-mediated necrotizing myopathy, myositis.
      - GU
        
        Erectile dysfunction
      - GI
        
        abdominal cramps, constipation, diarrhea, flatus, heartburn, drug-induced hepatitis, nausea, pancreatitis.
      - Endo
        
        hyperglycemia
      - EENT
        
        Rhinitis
      - Derm
        
        Rash, pruritis
      - CV
        
        Chest pain, peripheral edema
    - - Drug-Food
        
        Grapefruit juice
      - Drug-Drug
        
        Macrolide antibiotics
        
        Antiretrovirals
        
        Antifungals
  - - - Hypertension (as monotherapy or in combination with other antihypertensive agents).
      - Chronic stable angina
      - Adjunct therapy with diet and exercise in the management of type 2 diabetes
      - Coronary Artery Disease
    - - Inhibits the transport of calcium into myocardium and vascular smooth muscle cells, resulting in inhibition of excitation coupling and subsequent contraction.
      - Reduced BP
      - Decreases frequency and severity of attacks of angina
    - - Distribution
        
        Wide spread availability
      - Metabolism and excretion
        
        Mostly metabolized by the liver and excreted by renal system as metabolites
      - Absorption
        
        64-90% absorption following oral administration
      - Half-life
        
        30-50 hrs (higher in clients with hepatic impairment)
    - - Hypersensitivity
      - Systolic BP <90 mmHg.
    - - Aortic stenosis
      - Hx of Heart Failure
      - Severe hepatic impairment
      - Use during pregnancy/breast feeding only if the benefits outweigh the risks. Some other CCBs are more regularly prescribed and considered safer for the fetus than amlodipine.
      - Use with caution in older adults as overcorrection of BP leading to hypotension is possible.
    - - Derm
        
        Flushing
      - GI
        
        Gingival hyperplasia, nausea and vomiting
      - CV
        
        Peripheral edema, angina, bradycardia, hypotension, or palpitations.
      - Neuro
        
        Dizziness, fatigue
    - - Drug-Drug
        
        May interact with CNS depressants such as fentanyl and alcohol
        
        Additive effect with other antihypertensives
        
        May increase likelihood of drug toxicity with lithium
        
        CYP3A4 Inhibitors (Used as part of treatment of HIV-1 infection).
- - - - Explore weight loss options
      - Explore ways for the client to become more active
      - Set goals with client and family around lifestyle changes.
    - - Explore non-finger-prick blood glucose monitoring technologies to improve frequency and ease of testing.
  - - - Vitals
        
        Blood Pressure
        
        145/92 (High)
        
        Blood Glucose (random)
        
        18.2 mmol/L (high)
        
        Pulse Rate
        
        88 bpm (normal)
        
        Heart sounds
        
        Assess for irregularities (murmurs, bruits, gallops)
        
        Heart sounds normal
        
        Pulse
        
        Assess all peripheral pulses, compare bilaterally
        
        Temperature
        
        36.5C
        
        SpO2
        
        Respiratory
        
        Assess lung sounds front, back, and sides
        
        No lung irregularities to note
      - Foot and lower extremity assessment
        
        Assess client's skin taking note of turgor, warmth, dryness, cracks, swelling, blisters, and/or ulcers
        
        Assess client's peripheral pulses, compare bilaterally.
        
        Neurological Assessment
        
        Vibration test
        
        Client demonstrates reduced sensation in feet bilaterally following vibration test.
        
        Reflexes
      - Eye assessment
        
        Ask client about any recent changes to vision
        
        client reports no recent changes
        
        Refer client to eye specialist for comprehensive
        eye assessment. Development of glaucoma is common in those who are hypertensive and diabetic.
        
        Assess pupillary light reflex
      - Weight: 81kg
      - Height: 157cm
        
        BMI: 32.6 kg/m2 (Class 1 Obesity)