NR565 Week 5 Discussion Diabetes Management and Client Assessment 

Diabetes Management and Client Assessment 

Describe the Client’s Situation

Konane Pelekia is a 65-year-old female (DOB 12/1/1959) who presents for routine follow-up. Her recent work in the lab (NP- ordered annual physical) showed:

• Fasting blood glucose: 155 mg/dL
• HbA1c: 8.1%, with glycosuria on urinalysis
• Point-of-care glucose (today): 205 mg/dL
• BNP: 110 pg/mL (normal)
• Kidney function, potassium, cholesterol: Within normal limits
• Echocardiogram: EF 55% (HFpEF, Stage C, NYHA Class II)

Her past medical history includes hypertension and heart failure (diastolic stage C). Current medications are:

• Furosemide (Lasix) 20 mg PO BID
• Lisinopril (Zestril) 10 mg PO daily
• Metoprolol (Lopressor) 50 mg PO BID
• Aspirin 81 mg PO daily

She quit smoking 40 years ago and does not drink. Her vitals/ physical exam today:

• Height 5′7″; weight 250 lbs (BMI 39.2)
• BP 129/84 mm Hg; HR 61 bpm; RR 18; SpO₂ 96% on room air; T 98.6 °F

Konane is without acute complaints. The NP made a diagnosis of newly onset type 2 diabetes given her existing HFpEF and hypertension.

1. Assess the Applicable Clinical Practice Guideline (CPG)

Complication-centred approach: AACE 2023 T2D Management Algorithm (based on the 2022 AACE DM CPG). SGLT-2 inhibitor is advised in patients with T2D + HF (even with preserved EF) irrespective of glycemic control as a strategy to reduce heart failure hospitalizations and reduce cardiovascular (CV) mortality (Samson et al., 2023).

Additionally, Konane’s HbA1c is 8.1% (>7.5%), suggesting dual therapy with metformin (first-line) plus another agent (e.g., SGLT-2i) according to CPG recommendations (Samson et al., 2023).

1. Personal Professional Assessment & Pharmacological Treatment

Given Konane’s profile: T2D (HbA1c 8.1%), obesity (BMI 39.2), HFpEF (Stage C), and hypertension, 3 goals of pharmacotherapy should be met:

1. Improve Glycemic Control without Risk.
2. Reduce HF-related risk
3. Address obesity, if possible, through weight – friendly agents.

First Agent: Metformin

• Usual initial therapy in T2D without any renal derogation (eGFR 30 mL/min and above).
• Metformin 500mg PO BID Meal times to minimise GI side effects.

Second Agent: SGLT-2 Inhibitor (Canagliflozin)

• AACE CPG recommends an SGLT-2i – even if glycemia was controlled, – because of the HF benefit (Samson et al. 2023).
• Canagliftoin 100mg PO daily pre-prandial: Starting dose. May increase to 300 mg/day after 4 weeks if eGFR is OK, glycemic/HF goals are not met.
• Weight loss and slight natriuresis can also help in the management of HF and obesity.

Rationale Synthesis:

The SGLT-2 inhibitor canagliflozin reduces HF hospitalizations and CV mortality in T2D/HF patients (Abdelmasih et al., 2021; Zhou et al., 2022) and should be started at 100 mg/day, with a target of 300 mg if targets are not met within 3 months. Thus, the combination of metformin + canagliflozin can treat glycemia, reduce HF progression and CV risk, and promote weight reduction.

Additional Questions & Follow-up

Questions to Further Inform Treatment:

1. Renal Function Trends:
   • Confirm eGFR in 80-90mL/min range SGL T2i should not be used if E.G.F.R <45mL/min.
   • Baseline Creatinine, eGFR, microalbumin/creatinine ratio for screening of DKD.

1. Volume Status & Electrolytes:
   • In case of furosemide, HFpEF, watch out for hypotension/dehydration, CANagliflOzin.
   • Check BUN/Creatinine, Electrolytes (Na+, K+, Cl-).
2. HbA1c & Glucose Monitoring:
   • Follow up lab after 3 months HbA1c, fasting glucose, BMP
   • Home glucose logs should be encouraged to make the diagnosis of asymptomatic hypoglycemia.
3. Cardiovascular Risk Assessment:
   • Get lipid panel, non-HDL cholesterol, and Apo B if one has a dyslipidemia and treat aggressively.
   • Assess statin adherence – where required, to maximise atorvastatin (or start where not on a high-intensity statin).
4. Lifestyle & Weight Evaluation:
   • Referral to a dietitian to discuss caloric restriction; 510 percent weight loss to help decrease glycemia and HF symptoms.
   • Determine physical activity impairment of obesity/HFpEF; cardiac rehab may be needed.
5. HFpEF Monitoring:
   • Check BNP every 3 months and take into consideration the natriuretic peptide.
   • Evaluate change of NYHA classes, evidence of volume overload (JVD, crackles) at every visit.

1. Hypoglycemia Risk:
   • Metformin and SGLT-2i are linked to a low risk of hypoglycemia. However, in the case of later combined administration with another sulfonylurea or insulin, the patient must be informed about the risk of hypoglycemia.

Related discussion for your help: NR 565 Week 3