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Type 2 diabetes mellitus, hypertension, and hyperlipidemia often co-occur. Several hypotheses have been developed in an attempt to establish which condition comes secondary to the other and identify a rather complex nexus within which these conditions exist. Nevertheless, it is imperative to note that each of these pathologies can not only make the other worse but could also increase the risk of cardiovascular disease development. Evidence has it that a significant number of patients with all these three conditions have had difficulties gaining control over all of them. This essay gives a critical analysis of the case of a 59-year-old Hispanic male with type 2 diabetes on metformin 1000 mg, Amaryl 4 mg, Lipitor 40 mg, lisinopril/hydrochlorothiazide 40/25, and Tricor. The level of his latest glycated hemoglobin was 12% and his current blood pressure is 170/88 mmHg. Additionally, he has an office urine microalbumin value of 100 ?g/mg. The paper is aimed at providing plausible solutions to the existing drug therapy problems and ultimately, achieving the desired therapeutic outcomes.
Type 2 diabetes mellitus can be best regarded as a disease spectrum comprising many dysfunctions typified by hyperglycemia. These abnormalities are characterized by a combination of increased insulin requirement and reduced insulin secretion. These could stem from the increased tissue resistance to the hormone, inadequate secretion of insulin, or the inappropriate or excessing production and secretion of glucagon. Patients with type 2 DM typically suffer from an overproduction of triglyceride-rich lipoproteins from the hepatic cells. This is associated with the reduction in the levels of high-density lipoproteins. In cases of severe hyperglycemia, there is a notable decline in the enzymatic action of the muscle and adipose tissue lipoprotein lipase (LPL). As a result, there is a decrease in HDL levels accompanied with the defective breakdown of the triglyceride-rich lipoproteins by LPL. These events precipitate hyperlipidemia. A complex mechanism involving the renin-angiotensin-aldosterone system, insulin resistance, and hyperlipidemia is the reason for the occurrence of hypertension in this patient (Bharati, Tauro, Rawat, Pankaj, & Shrivastav, 2015).
The approach to the pharmacological treatment plan for the patient, in this case, would be to initiate triple anti-hypertensive therapy with an angiotensin-converting enzyme inhibitor/an angiotensin receptor blocker, a calcium channel blocker, and a thiazide-type diuretic. This is because, despite his current course of treatment, the patient's blood pressure is still above the normal level. Additionally, to achieve a tighter glycemic control, I would introduce a third agent, a glucagon-like peptide, one agonist such as liraglutide on top of the metformin and glimepiride that he already is taking. To treat the patients hyperlipidemia, I would replace the fenofibrate with ezetimibe as the latter has proved to provide incremental cardiovascular benefits compared to the use of fibrates when combined with statins (Ashfield Healthcare Communications, 2016). The optimal treatment goal for this patient would be to reduce his glycated hemoglobin levels to below 7.0% (American Diabetes Association, 2016). Additionally, I would aim to bring down the patients blood pressure to less than 140/90 mmHg as recommended by the Joint National Committee 8 guidelines (AJMC, 2014) as well as the American Diabetes Association.
Diuretics including hydrochlorothiazide and calcium channel blockers are known to induce hyperglycemia. As such, they may compromise the effectiveness of metformin and Amaryl. It is thus important that the patient regularly checks his glucose levels and reports any alarming fluctuations. However, the two agents are synergistic when used together. Lisinopril interacts with diuretics causing the reduction of blood pressure. Improper dosing and irrelevant monitoring could thus precipitate a hypotensive crisis. Its simultaneous administration with oral hypoglycemic agents could also lead to hypoglycemia. The patient should be advised to be on the lookout for any adverse drug reactions and report them to the primary care office as soon as possible.
The management and care of the patient in this case study would require the joint effort of an interdisciplinary team to guarantee the achievement of various treatment goals. The primary care physician (GP) would be the key participant in the process. This kind of professional plays a critical role in the primary diagnosis, execution of the evidence-based treatment, as well as the successive, follow up arrangements, all of which are aimed at optimizing the prognosis for the patients condition. Hyperlipidemia and high blood pressure are likely to trigger cardiovascular problems. Should any such adverse complications arise, it would be necessary to involve a cardiologist to conduct an investigation, create a plan, and initiate a viable therapeutic strategy.
Another critical member of the interdisciplinary team would be a pharmacist whose roles have already been well-defined. He or she would be tasked with checking the patient's medications for any interactions and highlight any possible adverse effects as well as the approaches to prevent them. Additionally, as an authoritative source of drug related information, a pharmacist would advise the physicians on the appropriate drug dosages and regimens. Pharmacists also bear the responsibility of informing the patient about the drugs he needs to take and ensuring that he complies with the treatment regimen. Registered nursing practitioners also play a significant role especially when it comes to the patient care. Their function is to educate and counsel the patient together with his family apart from offering the patient some assistance if he shows any adverse signs or symptoms, unresponsiveness to the therapy or deterioration.
The role of dieticians is also instrumental in the evaluation of dietary food intake and formulation of detailed advice depending on the patients specific needs in addition to ensuring the patients adherence to the prescribed nutritional recommendations. This kind of professionals would also help the patient realize the need to maintain a healthy body weight. Weigh reduction in the patient with multiple comorbidities would require the specialized guidance and expertise of a dietician as it is a rather complicated affair. Physical therapists should also become part of the healthcare team being tasked with managing this patient as they would give invaluable advice to the patient on the list of appropriate physical exercises to be done. Such information is critical for the training and subsequent recovery of the patient.
Due to the fact that diabetes is an endocrine disorder, the input of a specialized endocrinologist in the team would also be significant. Such a specialist would provide the necessary recommendations on how to achieve tight glycemic control while preventing the emergence of other endocrine complications. Additionally, optometrists and podiatrists could also get engaged in the treatment process. Diabetic patients are known to have such conditions as retinopathy and neuropathy, both of which can efficiently be managed by the specialists mentioned above. In the management of patients with chronic disorders as in this case, it is equally important to include a psychologist to help the patient deal with the effects of his conditions on his daily life. A psychologist can also help the primary caregivers to look out for and identify the symptoms of depression in the patient. Without any doubt, a team comprised of all these professionals would deliver a more holistic care to the patient as attention would be paid to every small detail of the management process. Additionally, it would guarantee better therapeutic outcomes and help minimize drug therapy related problems.
In addition to the pharmacological interventions required for the management of this patients condition, it is equally imperative to address his non-pharmacological needs and provide the necessary information on this issue. The most appropriate approach to adopt is based on such issues as the patients lifestyle, medications he takes, and associated risk factors. Optimal diet and proper aerobic and resistance exercise are the main tools used for the non-pharmacological management of the patient in this case. The patient should be aware of the fact that changes in body composition and weight with the loss of visceral and total body fat can have a significant impact on the blood lipid levels similar to that of several pharmacological remedies. It is prudent to educate the patient on the importance of making some changes in his lifestyle and habits. Such adjustments would include the reduction of his dietary intake of total and saturated fat, and excessive sugar being replaced by a diet rich in vegetables and fruits. The patient should also lower his sodium intake and increase his potassium intake.
A common side effect of using oral anti-diabetic drugs is hypoglycemia. It is, therefore, necessary to educate the patient on how to prevent hypoglycemic attacks. He should be advised to carry sweets and take them in case the symptoms of hypoglycemia occur. Additionally, it is important to instruct the patient on how to avoid stressful situations and maintain a peaceful state of mind. The patient should, however, be informed that the success of such lifestyle adjustments often becomes visible only in six to twelve months after their commencement. Besides, the attainment of reduced lipid levels with such modifications greatly varies, and as such, it is also important to strictly adhere to the medication regimen.
The maintenance of an optimized state of health in the case of this patient would involve various factors. First and foremost, it is imperative for the patient to have a valid medical insurance to cover his treatment needs and to eliminate the cases of non-compliance due to the lack of affordability. The patient should also adjust his health-seeking behavior and adhere to the stipulated health maintenance guidelines. These include undergoing wellness checks and screening tests, and getting all the recommended vaccinations. Most importantly, the patient should undergo all follow-up checks as prescribed by the physician.
In conclusion, the above-discussed case is just one of many examples when such conditions as type 2 diabetes, hyperlipidemia and hypertension occur together in one patient. However, the simultaneous management of all the three conditions can largely be a considerable challenge. Nevertheless, it has been shown that by following the existing treatment guidelines and algorithms, positive therapeutic outcomes can be achieved. Additionally, there is a need to engage a team of medical professionals from various health disciplines in the management of such patients. It is also essential to educate the patients on lifestyle modifications and to ensure that all their therapeutic needs are met to guarantee the desired outcomes.
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