Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So if you're ready, let's jump right in.
The NP is caring for a 68-year-old man with a 20 year-history of type 2 DM, HTN, dyslipidemia, obesity (BMI=32 kg/m2) stage 3A CKD who is currently taking all of the following medications at optimized doses and with adherence: ACEI, thiazide diuretic, a statin, and metformin. His current A1c= 8.2%. (NL= <5.6%), and states he is feeling well. Which of the following should be considered as next step therapy?
A. A sulfonylurea
B. Basal insulin
C. A SGLT2- inhibitor
D. No additional therapy as he is feeling well.
Well, where do you start?
Determine what kind of a question this is. And given this is a question focused on possibly adjusting therapy for an adult who is currently diagnosed with and being treated for multiple health conditions that often occur concurrently, that would be hypertension, dyslipidemia, type two diabetes and CKD. As a result, this is an evaluation question where the NP is being asked to consider response to care and if the patient is meeting treatment goals.
Let's take a look at the current ADA recommendations as well as the patient information we're given. First, the only lab parameter we're provided with is an A1c of 8.2%. And if you're thinking yourself, I want a lot more information about this patient, please keep in mind, on the NP boards, not at all uncommon to get a little bit of information like this, like just the A1c, and then you are to take it from there. But keep in mind, the boards will not ask you to answer a question where you have truly been given inadequate information. In other words, you've got all the information you need to answer this question in the narrative of the question, the body of the question, the patient's story.
So back to that A1c of 8.2%. The goal A1c of less than 7% for most people with type two diabetes per ADA applies here. As a result, we know his glycemic control is suboptimal and therapy needs to be adjusted. We also know the patient has established CKD and we're told that he's at stage 3A where the estimated GFR range is about 45 to 59. And keep in mind a normal GFR can be in excess of 90. The goal of renal protective therapy is to slow the irreversible loss of functional nephrons, therefore preserving GFR.
He's taking one medication that does provide this renal protection, an ACE inhibitor, a class of drugs with a -pril suffix. Keep in mind as well, an ARB could have been given, those are meds with a –sartan suffix instead of the ACE inhibitor. But important to keep in mind, never, ever, ever an ACE inhibitor and an ARB at the same time because there's too much hyperkalemia risk with that combo. So again, either an ACE inhibitor or an ARB, but never the two together.
The ADA now advocates the use for select diabetes meds and the presence of CKD, due to the evidence of their ability to help preserve renal function. These include the SGLT2I’s, -gliflozin suffix medications such as Canagliflozin and the GLP1 agonists. Many of these that have the -glutide suffix such as semaglutide. In addition, with obesity, which is one of this patient's diagnoses, the ADA advocates for patients to use medications that are associated with weight loss potential whenever possible. The reason for this, of course, is weight loss is associated with better diabetes outcomes.
Keep in mind as well, with hypertension, seldom is type two diabetes control achieved with a single medication, and most will need 2 to 3 and sometimes 4 medications from different classes. With this background information, let's take a look at the options we are given.
To recap the question, the NP is caring for a 68-year-old male with a 20-year history of type two diabetes, hypertension, dyslipidemia and obesity, as well as Stage 3A CKD who's currently taking all of the following medications at optimized doses and with adherence an ACEI, thiazide diuretic, statin, and metformin. His current A1c is 8.2%, and he states he's feeling well. Which of the following should be considered as next step therapy?
A. A sulfonylurea.
This drug class enhances insulin release, but without regard to blood glucose. Hypoglycemia with sulfonylurea use is a major issue. Well, this is not an incorrect answer. Choosing a sulfonylurea as the correct answer fails to address the issues of his comorbidity, especially CKD and obesity. This is the dilemma you're going to find on boards. This is a response that's not wrong, but it's not our best response. So we're not going to choose A as an option.
B. Basal insulin.
Again, this isn't a wrong answer, but it's not our best answer. Insulin is the most powerful A1c lowering medication. In type two diabetes, usually insulin is initiated once the patient has failed two or more insulin releasing drug classes, including a GLP1 agonist, DPP4 inhibitor and or sulfonylurea. According to the information we've been given, the patient has not received an insulin releaser. And in other words, this is not a wrong answer, but it's not the best answer.
C. A SGLT2- inhibitor.
This is our correct answer because this is the best answer. The use of this drug class, those with the –gliflozin suffix, aside from providing enhanced glycemic control, are typically associated with modest weight loss and have been associated with slowing CKD progression due in part to lowering intraglomerular pressure. The recommendations from the ADA on the use of a SGLT2I in a person with CKD includes keeping the patient on an ACE inhibitor or an ARB, and enhancing lipid control and glycemic control optimally to minimize the progression of the diabetic target organ dysfunction. In this case, seen as CKD. C is our correct answer because it's our best answer.
Now let's look at option D, no additional therapy because he's feeling well. Of course, this is incorrect. His A1c is nowhere near the goal of less than 7%, persistent hypoglycemia can contribute to diabetic target organ damage progression resulting in even more reduction of his GFR. Plus, of course, vascular and neuropathic issues. Patients are often without symptoms, even with persistently elevated blood glucose.
As I wrap up reviewing this question, I am going to toss in one more little nugget of information. You might be thinking, well, he's got CKD. should he remain on metformin? And metformin remains safe to use in people as long as the GFR is 30 or above. And with his stage A CKD, his GFR is well above that parameter.
The key takeaway: The ADA goals for treating type two diabetes include aiming for select glycemic goals to help minimize diabetes related target organ damage. While many medications will help lower A1c, certain medications have the advantage of minimizing currently present target organ damage, particularly its progression. Knowledge of these preferred medications is critical to safe practice and NP board success.
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