Responses 1. Cues that suggest the current management plan is not ideal include: a. FBS above goal of 80 to 130 mg/dL and A1C above goal of <7%. b. BP above goal. c. LDL above goal. d. Having an evening snack despite elevated fasting blood glucose. e. Eating shortly before going to bed, which can aggravate GERD symptoms. f. Weight gain being a common side effect of glipizide. g. Increased blood pressure, which is a common side effect of ibuprofen and often seen with weight gain. h. BMI of 34; compelling reason to consider medication for glycemia management that will not promote weight gain and may facilitate weight loss. i. Ibuprofen use, which may be aggravating GERD symptoms, risk for peptic ulcer disease. 2. Prioritize medication changes for P. R.: a. Discontinue glipizide, given risk for weight gain and inadequate control of blood glucose. b. Consider GLP-1 for management of blood glucose, which has added benefit of potential for weight loss c. Consider SGLT-2 for management of blood glucose. and added benefit of lowering blood pressure and protecting the heart and kidneys. Conclusion In patients with type 2 diabetes, achieving glycemic targets and reducing cardiorenal reduction requires an approach that balances age, comorbidities, and hypoglycemic risk. Many patients with type 2 diabetes also present with ASCVD, CKD, heart failure, and liver disease. The 2023 Standards of Medical Care in Diabetes (ElSayed et al., 2023a) highlights the impact of noninsulin antihyperglycemic agents on diabetes and Baker, C., Retzik-Stahr, C., Singh, V., Plomondon, R., Anderson, V., & Rasouli, N. (2021). Should metformin remain the first-line therapy for treatment of type 2 diabetes? Therapeutic Advances in Endocrinology and Metabolism, 12 , 1-13. https://doi. org/10.1177/2042018820980225 • Capoccia, K. L., & Odegard, P. S. (2022). Thiazolidinediones. In J. R. White (Ed.), 2022–2023 Guide to medications for the treatment of diabetes mellitus (pp. 121-141). American Diabetes Association. • Dang, D. K. (2017). Taking medication. In S. Cornell, C. Halstenson, & D. K. Miller (Eds.), The art and science of diabetes self-management desk reference (4th ed., pp. 169-189). American Association of Diabetes Educators. • Davies, M. J., Aroda, V. R., Collins, B. S., Gabbay, Jr. A., Green, J., Maruthur, N. M., Rosas, S. E., Prato, S. D., Mathieu, C., Mingrone, G., Rossing, P., Tankova, T., Tsapas, A., & Buse, J. B. (2022). Management of hyperglycemia in type 2 diabetes, 2022: A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes, (EASD). Diabetes Care, 45 (11), 2753-2786. https:/doi.org/10.2337/dci22-0134 • Davis, J., Fischl, A. H., Beck, J., Browning, L., Carter, A., Condon, J., Dennison, M., Francis, T., Hughes, P. J., Jamie, S., Lau, K. H., McArthur, T., McAvoy, K., Magee, M., Newby, O., Ponder, S., Quraishi, U., Rawlings, K., Socke, J., Stancil, M., Uelmen, S., & Willalobos, S. (2022). 2022 National standards for diabetes self-management education and support. The Science of Diabetes Self-Management and Care, 48 (1), 44-59. https://doi: 10.1177/26350106211072203 • ElSayed, N. A., Aleppo, G., Aroda, V. R., Bannuru, R. R., Brown, F. M., Bruemmer, D., Collings, B., Hilliard, M. E., Isaacs, D., Johnson, E. L., Kahan, S., Khunti K., Lean, J., Lyons, S. K., Perry, M. L., Prahalad, P., Pratley, R. E., Seley, J. J., Stanton, R. C., & Gabbay, R. A., on behalf of the American Diabetes Association. (2023a). 9. Pharmacologic approaches to glycemic treatment: Standards of care in diabetes, 2023 . Diabetes Care, 46 (Suppl 1), S140-S157. https://doi.org/10.2337/dc23-S009 • ElSayed, N. A., Aleppo, G., Aroda, V. R., Bannuru, R. R., Brown, F. M., Bruemmer, D., Collings, B., Hilliard, M. E., Isaacs, D., Johnson, E. L., Kahan, S., Khunti K., Lean, J., Lyons, S. K., Perry, M. L., Prahalad, P., Pratley, R. E., Seley, J. J., Stanton, R. C., & Gabbay, R. A., on behalf of the American Diabetes Association. (2023b). 6. Glycemic targets: Standards of care in diabetes, 2023. Diabetes Care, 46 (Suppl 1), S97-S110. https://doi.org/10.2337/ dc23-S006 • Fisman, E. Z., & Tenenbaum, A. (2021). The dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (LP-1) receptor agonist tirzepatide: A novel cardiometabolic therapeutic prospect. Cardiovascular Diabeolgy, 2 0, 225. https://doi. org/10.1186/s12933-021-01412-5 • References • Frias, J. P. (2020). Tirzepatide: A glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) dual agonist in development for the treatment of type 2 diabetes. Expert Review of Endocrinology & Metabolism, 16 (6), 379i-394. https://doi.org/10 .1080/17446651.2020.1830759 • Garber, A. J., Handelsman, Y., Grunberger, G., Einhorn, D., Abrahamson, M. J., Barzilay, J. I., Blonde, L., Bush, M. A., DeFronzo, R. A., Garber, J. R., Garvey, W. T., Hirsch, I. B., Jellinger, P. S., McGill, J. B., Mechanick, J. I., Perreault, L., Rosenblit, P. D., Samson, S., & Umpierrez, G. E. (2020). Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm: 2020 executive summary. Endocrine Practice, 26 (1), 107- 139. https://doi:10.4158/CS-2019-0472 • Hickson, R. P., Cole, A. L., & Dusetzina, S. B. (2019). Implications of removing rosiglitazone’s black box warning and restricted access program on the uptake of thiazolidinediones and dipeptidyl peptidase-4 inhibitors among patients with type 2 diabetes. Journal of Managed Care & Specialty Pharmacy, 25 (1), 72-79. https://doi.org/10.18553/jmcp.2019.25.1.072 • Jastreboff, A. M., Aronne, L. J., Ahmad, N. N., Wharton, S., Connery, L., Alves, B., Kiyosue, A., Zhang, S., Liu, B., Bunck, M. C., & Stefanski, A., for the SURMONT-1 Investigators. (2022). Tirzepatide once weekly for the treatment of obesity. New England Journal of Medicine, 387 (3), 205-216. https://doi: 10.1056/NEJMoa2206038
d. Consider need for moderate-dose statin therapy per ADA guidelines for adults with diabetes. e. Consider discontinuation of famotidine and initiation of proton pump inhibitor to better control GERD symptoms. f. Consider acetaminophen and physical therapy for bursitis and discontinuation of ibuprofen, given risk of elevated blood pressure and potential increased risk of PUD. 3. Prioritize the teaching needs for PR regarding self- management of his health: a. Purpose and side effects of new medications prescribed and the importance of reporting any side effect or intolerance to the PCP. b. Appropriate injection technique with addition of a GLP‑1. c. Relationship of dietary intake to glycemia, with referral to CDCES for nutrition teaching and general diabetes management education. d. Recognition of foods that can help to lower LDL cholesterol. e. Guidance on nonpharmacologic interventions for management of GERD (weight loss, not lying down within two hours of eating, raise head of bed 30 degrees, avoid tight garments around the waist, avoid dietary triggers). comorbidities of care. With healthcare providers needing to address more than blood glucose, newer agents like glucagon- like peptide 1 receptor agonists (GLP-1 RA), sodium-glucose cotransporter 2 inhibitors (SGLT2i), dipeptidyl peptidase-4 (DPP- 4) inhibitors, and glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 RA are coming to the forefront as first-line therapy by themselves or in combination with other agents. • Kroon, L., & Zhou, C. (2022a). Sulfonylureas. In J. R. White (Ed.), 2 022–2023 Guide to medications for the treatment of diabetes mellitus (pp. 142-156). American Diabetes Association. • Kroon, L., & Zhou, C. (2022b). Glinides. In J.R. White (Ed.), 2022–2023 Guide to medications for the treatment of diabetes mellitus (pp. 157-168). American Diabetes Association. • Lebovitz, H. E. (2017). Thiazolidinediones: The forgotten diabetes medications. Current Diabetes Reports, 19 , 151. https://doi.org/10.1007/s118292-019-1270-y • Matthews, D. R., Paldanius, P. M., Proot, P., Chiang, Y. T., Stumvoll, M., Del Prato, S., & VERIFY Study Group. (2019). Glycaemic durability of an early combination therapy with vildagliptin and metformin versus sequential metformin monotherapy in newly diagnosed type 2 diabetes (VERIFY): A 5-year, multicentre, randomized, double-trial trial. The Lancet, 394 (10208), 1519-1529. https://doi.org/10.1016/S0140-6736(19)32131-2 • McKeirnan, K. C., & Neumiller, J. J. (2022). Dipeptidyl peptidase-4 (DPP-4) inhibitors. In J. R. White (Ed.), 2022–2023 Guide to medications for the treatment of diabetes mellitus (pp. 194-208). American Diabetes Association. • McKeirnan, K. C., & Rodin, N. M. (2022). Alpha-glucosidase inhibitors. In J. R. White (Ed.), 2022–2023 Guide to medications for the treatment of diabetes mellitus (pp. 186-193). American Diabetes Association. • Neal, B., Perkovic, V., Mahaffey, K. W., de Zeeuw, D., Fulcher, G., Erondu, N., Shaw, W., Law, G., Desai, M., & Matthews, D. R. for the CANVAS Program Collaborative Group. (2017). Canagliflozin and cardiovascular and renal events in type 2 diabetes. New England Journal of Medicine, 377 (7), 644-657. https://doi: 10.1056/NEJMoa1611925 • Neuen, B. L., Arnott, C., Perkovic, V., Figtree, G., de Zeeuw, D., Fulcher, G., Jun, M., Jardine, M. J., Zoungas, S., Pollock, C., Mahaffey, K. W., Neal, B., & Heerspink, H. J. L. (2021). Sodium-glucose co-transporter-2 inhibitors with and without metformin: A meta- analysis of cardiovascular, kidney and mortality outcomes. Diabetes, Obesity & Metabolism, 2 3(2), 382-390. https://doi.org/10.1111/dom.14226 • Odegard, P. S., & Capoccia, K. L. (2022). Biguanides. In J. R. White (Ed.), 2 022–2023 Guide to medications for the treatment of diabetes mellitus (pp. 93-120). American Diabetes Association. • Powers, M. A., Bardsley, J. K., Cypress, M., Funnell, M. M., Harms, D., Hess-Fischl, A, Hooks, B., Isaacs, D., Mandel, E. D., Maryniuk, M. D., Norton, A., Rinker, J., Siminerio, L. M., & Uelman, S. (2020). Diabetes self-management education and support in adults with type 2 diabetes: A consensus report of the American Diabetes Association, the Association of Diabetes Care and Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists. The Diabetes Educator, 46 (4), 350-369. https://doi.org/10.1177/0145721720930959 • Rena, G., Hardie, D. G., & Pearson, E. R. (2017). The mechanism of action of metformin. Diabetologia, 60 , 1577-1585. https://doi.org/10.1007/s00125-017-4342-z • Scheen, A. J. (2021). Sulphonylureas in the management of type 2 diabetes: To be or not to be? Diabetes Epidemiology and Management, 1 , 1-8. https://doi.org/10.1016/j. deman.2021.100002 • Sisson, E. M., & Zimmerman, K. M. (2017). Pharmacotherapy for glucose management. In S. Cornell, C. Halstenson, & D. K. Miller (Eds.), The art and science of diabetes self- management desk reference (4th ed., pp. 469-516). American Association of Diabetes Educators. • Sola, D., Rossi, L., Schianca, G. P., Maffioli, P., Bigliocca, M., Mella, R., Corliano, F., Fra, G. P., Bartoli, E., & Derosa, G. (2015). Sulfonylureas and their use in clinical practice. Archives of Medical Science, 11 (4), 840-848. https://doi.org/10.5114/amos.2015.53304 • Trujillo, J. M. (2022). Glucagon-like peptide-1 receptor agonists. In J. R. White (Ed.), 2022–2023 medications for the treatment of diabetes mellitus (pp. 209-233). American Diabetes Association. • White, J. R. (2022). SGLT2 inhibitors. In J. R. 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