DNP 815Aquifer Internal Medicine Essay

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In particular, cardiovascular disease is the No. 1 cause of mortality for people with diabetes, and one of the top causes of morbidity.

Hypoglycemia, infections, foot ulcers, and amputations are additional causes of morbidity and mortality in patients with diabetes.

The American Diabetes Association publishes annual guidelines to assist in the management of a patient with diabetes.

Remember the large role that the psychosocial aspects of a diabetesRemember the large role that the psychosocial aspects of a diabetes diagnosis play in managementdiagnosis play in management

Non-adherence with medical recommendations could be due to economic, work-related, religious, social, or linguistic barriers to care. Care must be taken to assess the psychosocial status of each person with diabetes at each clinic visit to ensure that barriers to successful diabetes care are minimized.

Question Which of the following does the American Diabetes Association recommend to minimize the risk of cardiovascular disease in patients with diabetes? Select all that apply.

TEACHING POINTTEACHING POINT

http://care.diabetesjournals.org/content/41/Supplement_1
The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Smoking cessation

B. Daily aspirin therapy

C. Blood pressure less than 140/90 mmHg (if it can be

achieved without increased treatment burden, a systolic target of < 130

is appropriate in younger, healthier patients)

D. If > 40 years old, regardless of other atherosclerotic

cardiovascular disease risk factors, statin therapy

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Answer Comment > The correct answers are A, B, C, D> The correct answers are A, B, C, D

ADA Recommendations to Minimize the Risk of Cardiovascular Disease in Patients with Diabetes Smoking cessationSmoking cessation, daily aspirindaily aspirin, blood pressure controlblood pressure control and lipid controllipid control are all recommended to reduce the risk of cardiovascular disease. Aquifer Internal Medicine Essay

Please note that as of 2018, ADA recommendations were published with the older definition of hypertension (140/90). It always takes time before multiple different organizations agree on the same thresholds.

Daily low dose aspirin is recommended for primary prevention of cardiovascular disease in diabetic patients with a 10-year risk of atherosclerotic cardiovascular disease of >10%. It is also recommended for secondary prevention of all diabetic patients with a history of atherosclerotic disease.

Reduction of cardiovascular risk is achieved with a goal of optimal glycemic control, as well as control of many other health factors that raise cardiovascular risk, such as tobacco use, obesity, poorly controlled hypertension, and hypercholesterolemia.

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References Economic Costs of Diabetes in the U.S. in 2012. American Diabetes Association. Diabetes Care. April 2013; 36(4):1033-1046. http://care.diabetesjournals.org/content/36/4/1033. Accessed May 11, 2018.

PATIENT HISTORY HISTORY

Mr. Morales tells you about his heart attack.Mr. Morales tells you about his heart attack.

You enter the exam room and introduce yourself to Mr. Morales.

“What brought you to the oRce today?” “I had a heart attack about a month ago and had to have open-heart surgery. The heart doctors told me that my heart is weak now. My cardiologist told me that I have to get my blood sugar under control so I don’t have another heart attack. I am here to get down to work.”

“Tell me more about that.” “I didn’t come back to see Dr. Clay because my job at the furniture factory wouldn’t give me time off for clinic appointments, and I couldn’t risk losing

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” DEEP DIVEDEEP DIVE

http://care.diabetesjournals.org/content/36/4/1033
The best option is indicated below. Your selections are indicated by the shaded boxes.

my job. I wasn’t checking my blood sugar before my heart attack because the testing strips are so expensive and my supervisor wouldn’t let me off the line to check anyway. Since my surgery, I haven’t gone back to work, and I’ve been checking my sugar before each meal and before bed. The hospital social worker got me two months’ worth of testing strips and lancets before I went home, but I’m going to run out in a couple of weeks. I’m worried that I won’t be able to check anymore.”

He also tells you that while he was in the hospital, they had to use insulin through his vein to keep his blood sugar controlled, and that was very upsetting to him.

Question True or False: In a critically ill medical patients, tight blood sugar control with intravenous insulin therapy, with a goal blood sugar of 80-110 mg/dL, is associated with lower mortality than less tight blood sugar control (e.g. 140-180 mg/dL).

A. True

B. False

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Answer Comment > The correct answer is B> The correct answer is B

EUectiveness of Intravenous Insulin for Blood Glucose Control Blood sugar control in critically ill patients has been the subject of considerable investigation. Previous research suggested that tight control (80-120 mg/dL) was desirable, but more recent research shows that aggressive blood sugar control can be associated with higher mortality.

Hypoglycemia (serum glucose concentration <70 mg/dL), with rates as high as 40% in some studies, is associated with tight glycemic control.

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A meta-analysis of 29 controlled trials involving more than 8,000 adult ICU patients showed no difference in in-hospital mortality between the group assigned to tight glucose control versus usual care. Aquifer Internal Medicine Essay

The current recommended blood glucose target for mostThe current recommended blood glucose target for most hospitalized patients is 140 to 180 mg/dL.hospitalized patients is 140 to 180 mg/dL.

References Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008;300(8):933.

MEDICATION REVIEW HISTORY You review Mr. Morales’ medications with him:

MedicationsMedications

metformin 1000 mg twice daily pioglitazone 15 mg daily glipizide 5 mg daily aspirin 81 mg daily clopidogrel 75 mg daily long-acting metoprolol 100 mg daily furosemide 80 mg twice daily lisinopril 20 mg daily amlodipine 10 mg daily ranitidine 150 mg twice daily gabapentin 300 mg twice daily potassium chloride 10 mEq twice daily atorvastatin 80 mg daily

Mr. Morales says, “The hospital doctors sent me home on an insulin shot – 40 units in my belly every night before I go to bed. I don’t like giving myself the shot, so sometimes I just don’t, but I take all the rest of my medicines like they told me to.”

He takes out the vial of insulin, and you see that it is insulin glargine.

Question

The best option is indicated below. Your selections are indicated by the shaded boxes.

Which of the following medications should you consider discontinuing in this patient based on your knowledge of his reduced ejection fraction? Choose the single best answer.

A. Pioglitazone

B. Atorvastatin

C. Aspirin

D. Glipizide

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Answer Comment > The correct answer is A> The correct answer is A

Thiazolidinediones Pioglitazone (A),Pioglitazone (A), a member of the class of drugs known as thiazolidinediones (TZD), is not recommended for use in patients who have newly developed heart failure and in those with known NYHA Class III and IV heart failure. The same is true for rosiglitazone, another TZD that has been associated with an increased risk of cardiovascular disease.

Mechanism of action:Mechanism of action: TZDs are peroxisome proliferator-activated receptor-gamma (PPARgamma) agonists. Aquifer Internal Medicine Essay