Please Reply to the following 2 Discussion posts: Requirement APA format with intext citation Word count minimum of 150 words per post, not including References References at least one high-level scholarly reference per post within the last 5 years in APA format. Plagiarism free. Turnitin receipt. DISCUSSION POST # 1 Reply to Elaine The patient in this case study has an elevated A1C, elevated lipid levels, and a moderate risk for cardiovascular disease. Based on the American Diabetes Association (ADA) guidelines this patient should be started on metformin and lifestyle modifications including diet and physical activity plans which also fit the patient's request not to be on insulin (ADA, 2022; Brock, 2020). Metformin remains the mainstay for initial diabetes management and is also useful for weight loss. Metformin is a biguanide, brand names include Glucophage and Fortamet, and works by increasing insulin receptor sensitivity in target tissues of skeletal muscles and adipose cells, reducing glucose absorption from the GI tract, and inhibiting glucose production in the liver (Rosenthal & Burchum, 2021). For this patient, I recommend starting with oral Glucophage XR 500mg once daily at night with meals. The medication is generally well tolerated with mild complaints of gastrointestinal upset, with rare cases of lactic acidosis reported.             Contraindications for metformin include IV contrast since they are both excreted by the kidneys and can result in an increased risk for lactic acidosis (Rosenthal and Burchum, 2021). Ideally, the patient should stop taking metformin 48 hours prior to the use of IV contrast for radiological procedures and drink plenty of water. A patient that is also taking levothyroxine may need to have their metformin dose increased since levothyroxine will inhibit metformin uptake.            Some other weight-neutral medication classes for diabetes include dipeptidyl peptidase-4 inhibitors, alpha-glucosidase inhibitors, and bromocriptine-QR (ADA, 2022; Brock, 2020). Some weight loss diabetic medications include metformin as we discussed, glucagon-like peptide-1 receptor antagonist, sodium-glucose cotransporter 2 inhibitors, and pramliontide. Jenuvia, generic name sitagliptin, is an example of a dipeptidyl peptidase-4 inhibitor (Rosenthal & Burchum, 2021).             Due to the patient's symptoms and complaints at the six-month follow-up visit, I would recommend the initial lab of the following: complete metabolic panel, complete blood count, thyroid panel, hemoglobin A1C, and vitamin B-12 levels. Metformin can cause a decrease in vitamin B12 levels which can cause some of these symptoms including fatigue (Rosenthal & Birchum, 2021; Ankar & Kumar, 2022).            According to Hennessey & Esplaillant (2018), the guidelines still recommend monotherapy for treatment of hypothyroid patients. The standard treatment is thyroid hormone replacement using levothyroxine, brand name Synthroid (Ch.

1. Please Reply to the following 2 Discussion posts:
Requirement
APA format with intext citation
Word count minimum of
150 words per post, not including References
References at least one high-level scholarly reference per post
within the last 5 years in APA format.
Plagiarism free.
Turnitin receipt.
DISCUSSION POST # 1 Reply to Elaine
The patient in this case study has an elevated A1C, elevated
lipid levels, and a moderate risk for cardiovascular disease.
Based on the American Diabetes Association (ADA) guidelines
this patient should be started on metformin and lifestyle
modifications including diet and physical activity plans which
also fit the patient's request not to be on insulin (ADA, 2022;
Brock, 2020). Metformin remains the mainstay for initial
diabetes management and is also useful for weight loss.
Metformin is a biguanide, brand names include Glucophage and
Fortamet, and works by increasing insulin receptor sensitivity in
target tissues of skeletal muscles and adipose cells, reducing
glucose absorption from the GI tract, and inhibiting glucose
production in the liver (Rosenthal & Burchum, 2021). For this
patient, I recommend starting with oral Glucophage XR 500mg
once daily at night with meals. The medication is generally well
tolerated with mild complaints of gastrointestinal upset,
with rare cases of lactic acidosis reported.
Contraindications for metformin include IV contrast
since they are both excreted by the kidneys and can result in an
increased risk for lactic acidosis (Rosenthal and Burchum,

2. 2021). Ideally, the patient should stop taking metformin 48
hours prior to the use of IV contrast for radiological
procedures and drink plenty of water. A patient that is also
taking levothyroxine may need to have their metformin dose
increased since levothyroxine will inhibit metformin uptake.
Some other weight-neutral medication classes for
diabetes include dipeptidyl peptidase-4 inhibitors, alpha-
glucosidase inhibitors, and bromocriptine-QR (ADA, 2022;
Brock, 2020). Some weight loss diabetic medications include
metformin as we discussed, glucagon-like peptide-1 receptor
antagonist, sodium-glucose cotransporter 2 inhibitors, and
pramliontide. Jenuvia, generic name sitagliptin, is an example
of a dipeptidyl peptidase-4 inhibitor (Rosenthal & Burchum,
2021).
Due to the patient's symptoms and complaints at the six-
month follow-up visit, I would recommend the initial lab of the
following: complete metabolic panel, complete blood count,
thyroid panel, hemoglobin A1C, and vitamin B-12 levels.
Metformin can cause a decrease in vitamin B12 levels which
can cause some of these symptoms including fatigue (Rosenthal
& Birchum, 2021; Ankar & Kumar, 2022).
According to Hennessey & Esplaillant (2018), the
guidelines still recommend monotherapy for treatment of
hypothyroid patients. The standard treatment is thyroid hormone
replacement using levothyroxine, brand name Synthroid
(Chiovato et al., 2019; Rosenthal & Burchum, 2021). The initial
starting dose for adults is recommended under the age of 50
years is 1.6 mcg/kg per day orally (Chiovato et al., 2019).
Levothyroxine should be taken in the morning on an
empty stomach 1 hour prior to meals (Rosenthal & Burchum,
2021). Levothyroxine is generally well tolerated however in
rare situations it can lead to thyrotoxicosis which can lead to
serious complications such as hypertension, tachycardia,
hyperthermia, tremors, acute psychosis, and myocardial
infarctions (Nguyen & Jialal, 2022). Additionally, chronic
overuse of levothyroxine can increase the incidence of bone loss

3. and atrial fibrillation (Rosenthal & Burchum, 2021).
Drugs that reduce the absorption of levothyroxine
include minerals like magnesium salts, calcium supplements,
aluminum-containing medications, and iron supplements
(Rosenthal & Burchum, 2021). The following medications may
also reduce the absorption of levothyroxine including histamine
2 receptor blockers, proton pump inhibitors, sucralfate,
cholestyramine, orlistat, furosemide, and colestipol (Eghtedari
& Correa, 2022; Rosenthal & Burchum, 2021). As a result of the
decreased absorption caused by these medications,
levothyroxine should be given at least four hours before
administering these supplements or medications.
Levothyroxine can affect the metabolism or uptake of
several drugs including phenytoin, carbamazepine, rifampin,
sertraline, and phenobarbital, warfarin, metformin, insulin, and
digoxin so these drug dosages may need to be increased or
decreased accordingly (Rosenthal & Burchum, 2021).
DISCUSSION POST # 2 Reply to Astrid
There are different classes of drugs for the treatment of type 2
diabetes mellitus (T2DM) that work in different ways to lower
blood glucose levels and have the added benefit of weight loss,
while others are considered weight neutral. For instance, the
DM medications Byetta (exenatide) and Invokana
(canagliflozin) cause weight loss and belong to the drug classes
glucagon-like peptide-1 receptor agonists (GLP-1 RA) and
sodium-glucose co-transporter 2 inhibitors (SGLT- 2i),
respectively (Apovian et al., 2019). Some sources state that
Glucophage (metformin), which belongs to a drug class called
biguanide, causes weight loss, while others state that it is a
weight-neutral drug (Apovian et al., 2019; Rosenthal &
Burchum, 2021). Januvia (sitagliptin) is a dipeptidyl peptidase-
4 (DPP4) inhibitor that is weight neutral.
Based on the current guidelines of the American
Diabetes Association (ADA) (2022), it would be appropriate to

4. treat the patient with monotherapy since she is hesitant to take
any injections. The first-line therapy in treating and managing
T2DM includes metformin and comprehensive lifestyle changes
(i.e., heart-healthy diet, increased physical activity, weight loss,
glycemic and blood pressure control, and lipid management).
Metformin, which falls under various brand names of
Glucophage, Glucophage ER, Fortamet, Glumetza, and Riomet,
lowers blood glucose levels and tolerance by insulin receptors
in target tissues, such as fat and skeletal muscle, resulting in
increased glucose uptake in response to whatever insulin is
available (Rosenthal & Burchum, 2021). The initial
recommended dose of metformin is 500 mg by mouth once a
day, Wexler (2022) recommends taking metformin in the
evening with or after dinner to reduce the chance of getting side
effects, such as nausea, diarrhea, and decreased appetite.
Furthermore, metformin and other biguanides are
contraindicated in many individuals with chronic kidney disease
(glomerular filtration rate < 30 ml/min), cirrhosis, congestive
heart failure, and respiratory insufficiency associated with
hypoxemia (Stoica et al., 2019). Biguanides impede
mitochondrial oxidation of lactic acid, which can cause lactic
acidosis. Metformin has a black box warning for lactic acidosis,
where too much lactic acid builds up in the blood and cannot be
eliminated easily, resulting in metabolic acidosis. Individuals
should be aware of early signs of lactic acidosis, such as
hyperventilation, respiratory distress, malaise, and myalgia
(Rosenthal & Burchum, 2021).
Moreover, the patient must always start with lifestyle
changes before starting her on medications for hypertension
(HTN) and dyslipidemia. To confirm the diagnosis of HTN, the
patient must have a BP ≥ 130/80 on two occasions (Rosenthal &
Burchum, 2021). Antihypertensive must be initiated when the
target BP goal is not achieved with lifestyle modifications.
However, according to the American College of
Cardiology/American Heart Association (ACC/AHA), the
patient has stage I hypertension (138/74) with a calculated 10-

5. year ASCVD risk of 6.2%. Patients with T2DM should achieve
a target BP of < 130/88 (Joseph et al., 2022). Initiating an
angiotensin-converting enzyme inhibitor (ACEI), which is the
preferred therapy for managing co-existing DM and HTN, may
slow the progression to cardiovascular mortality (Joseph et al.,
2022). ACC also recommends moderate-intensity statin therapy
in adults 40-75 years of age with DM regardless of estimated
10-year ASCVD risk. Therefore, the patient can be started on
Lisinopril 10 mg by mouth once a day for HTN and Atorvastatin
10 mg by mouth once a day at bedtime for lipid management.
During the six months follow-up, the patient complains
of fatigue, constipation, heavy and irregular menses, dry skin,
and brittle fingernails, some of the clinical manifestations of
hypothyroidism. To confirm this diagnosis and evaluate her
thyroid function, a thyroid function test that includes serum
thyroid-stimulating hormone test (TSH), T3 (triiodothyronine),
and T4 (thyroxine) should be performed. Since the anterior
pituitary is extremely sensitive to changes in thyroid hormone
levels, measuring serum TSH is the most sensitive approach for
detecting hypothyroidism (Rosenthal & Burchum, 2021). This
means that even a slight drop in serum T3 and T4 can result in
an extreme increase in serum TSH. Therefore, an excessively
high TSH level is indicative of hypothyroidism, even at a mild
level. For instance, elevated TSH, low T3, and low T4 levels
indicate hypothyroidism. Conversely, a low TSH level with
elevated T3 and T4 levels indicates hyperthyroidism.
The treatment of choice for hypothyroidism is thyroid
hormone replacement therapy (Ross, 2022). The standard
replacement therapy is the generic drug levothyroxine; trade
names include Levoxyl, Synthroid, Levothroid, Tirosint,
Euthyrox, and Unithroid. Levothyroxine is a synthetic version
of the body’s endogenous thyroid hormone: thyroxine (T4).
Levothyroxine is converted to its active metabolite T3 in
peripheral tissues, binding to thyroid receptor proteins within
the nucleus (Eghtedari & Correa, 2022). Once inside the
nucleus, thyroid hormones stimulate energy and the heart,

6. promote growth and development, and influence gene
transcription, causing protein synthesis. The recommended
initial dose is 1.6 mcg/kg/day with a 12.5 to 25 mcg/day dose
adjustment every six to eight weeks as needed. The patient must
take one tablet of the initial dose prescribed by mouth once a
day, on an empty stomach, preferably in the morning.
According to Rosenthal & Burchum (2021),
levothyroxine rarely causes adverse effects when administered
in appropriate dosage. However, when taken more than what is
prescribed, thyrotoxicosis may result. The patient must be
informed about the signs and symptoms of thyrotoxicosis
(tachycardia, nervousness, hyperthermia, heat intolerance,
angina, diaphoresis, and tremors) and instructed to notify the
prescriber as soon as possible. Other overdose-associated
symptoms are increased risk for atrial fibrillation and
accelerated bone loss.
In addition, it is vital to provide the patient with
education about the importance, risks, and benefits of this life-
long hormone replacement therapy. The patient must be
instructed to take the drug on an empty stomach in the morning,
at least 30 to 60 minutes before breakfast because food reduces
the absorption of oral levothyroxine, and to monitor TSH six
weeks after initiating therapy. Lab tests should indicate normal
plasma levels of TSH and T4. Once TSH has been stabilized,
monitoring and measuring TSH levels at least once a year is
essential. Additional education about this medication includes
drug interactions with products containing iron, calcium,
magnesium, iron, and aluminum, histamine-2 receptor blockers,
and proton pump inhibitors. Therefore, the patient must be
cautious with over-the-counter drugs that can reduce the
absorption of levothyroxine.