NUR 7071 Module 5 Type 2 Diabetes Case Paper: Adding Agents With Heart and Kidney Benefit After Metformin Example

Beyond the A1C: Choosing Diabetes Drugs for the Heart and Kidneys

Student Name

M.S. in Nursing, Family Nurse Practitioner, Thomas Edison State University

NUR-7071: Adult Primary Care Part I

Mentor Name

Month Day, Year

Beyond the A1C: Choosing Diabetes Drugs for the Heart and Kidneys

The Patient

Rosa Delgado, an invented 61-year-old school cafeteria worker, learned she had type 2 diabetes six years ago. Her medicines are metformin 1,000 mg two times a day, lisinopril 20 mg, atorvastatin 40 mg and aspirin, which she began when a stent was placed for a heart attack three years ago. Over the past year her A1C climbed from 7.4 percent to 8.4 percent. Her body mass index is 34, her blood pressure 132/80 and her estimated glomerular filtration rate 68. Her urine albumin-to-creatinine ratio is 45 mg/g on two samples, indicating moderately increased albuminuria. She is tired of "adding pills" and worried about low blood sugar at work, where she stands for long shifts.

What the Standards Recommend

Current standards ask clinicians to choose diabetes drugs with cardiovascular and kidney risk and weight in mind, not glucose alone (American Diabetes Association Professional Practice Committee, 2024). For adults with established atherosclerotic cardiovascular disease, it recommends a GLP-1 receptor agonist or SGLT2 inhibitor with proven cardiovascular benefit, regardless of A1C and whether or not metformin is used. For adults with chronic kidney disease and albuminuria, it recommends an SGLT2 inhibitor to reduce kidney disease progression and cardiovascular events. For weight management, it notes that GLP-1 receptor agonists and dual agonists provide the largest weight reductions. A common A1C goal for many nonpregnant adults is below 7 percent, individualized to the person, and agents with low hypoglycemia risk are preferred when hypoglycemia is a concern.

Evidence for an SGLT2 Inhibitor

Zinman et al. (2015) studied 7,020 people living with type 2 diabetes and known heart or vascular disease, giving each by chance either empagliflozin or placebo added to usual care. Across roughly three years of follow-up, the drug cut a three-part outcome, deaths from cardiovascular causes plus nonfatal heart attacks and strokes, by 14 percent. Cardiovascular death fell by 38 percent, hospitalization for heart failure by 35 percent and death from any cause by 32 percent. Genital infections were more common with empagliflozin.

Evidence for a GLP-1 Receptor Agonist

Marso et al. (2016) randomly assigned 9,340 adults with type 2 diabetes at high risk of heart events to liraglutide or placebo. Followed for a median of almost four years, patients given liraglutide had 13 percent fewer events in the same three-part cardiovascular outcome, along with lower cardiovascular and all-cause death rates. Nausea and other gastrointestinal effects were the most common reasons for stopping the drug. Liraglutide also lowered weight and A1C compared with placebo.

Sequencing Two New Drugs

Ms. Delgado has indications for both classes: heart disease for either, albuminuria for the SGLT2 inhibitor and obesity for the GLP-1 receptor agonist. Starting both at once would make side effects hard to sort out and would add to her sense of being overwhelmed. We agreed to begin empagliflozin 10 mg daily now, because it is a single pill, has low hypoglycemia risk and protects both heart and kidneys, and to add weekly semaglutide, a GLP-1 receptor agonist with demonstrated cardiovascular benefit, at her next visit in four weeks if her A1C remains above goal. Metformin continues because her kidney function allows it.

Safety Teaching

For empagliflozin, I explained the signs of genital yeast infection and how to keep the area clean and dry, the need to drink enough fluids during hot kitchen shifts and sick-day rules: stop the drug when she cannot eat or drink, has vomiting or is preparing for surgery, because of the rare risk of ketoacidosis with normal glucose levels. Her blood sugar is unlikely to drop low on these medicines, which eased her worry about work.

Weight and Her Own Goals

When asked what mattered most, Ms. Delgado said she wanted to keep up with her grandchildren and stop feeling sluggish after lunch at work. Both drug classes chosen tend to lower weight, empagliflozin modestly and semaglutide more substantially, which made the plan feel like a step toward her goals rather than another pill. We set a first target of losing 5 percent of her weight over six months, an amount that improves glucose, blood pressure and lipids, and she agreed to try a 15-minute walk after her shift on three days a week.

Comprehensive Care

Her kidney findings also support continuing lisinopril at the maximum tolerated dose, which was confirmed. She is due for a dilated eye examination and a foot examination with monofilament testing, both completed or scheduled. She was referred to diabetes self-management education, which her employer's plan covers, and to a dietitian. Her atorvastatin was increased to 80 mg, a high-intensity dose appropriate after her heart attack.

Barriers and Access

GLP-1 receptor agonists can be expensive. I checked her formulary before the next visit and found semaglutide covered with prior authorization, which the clinic will request. If coverage fails, liraglutide or another covered agent with cardiovascular benefit would be considered.

Follow-Up

She will return in four weeks for a basic metabolic panel, to check kidney function and potassium after starting empagliflozin, and to discuss starting semaglutide. Her A1C will be repeated in three months, and her urine albumin in six months.

Limits

Both trials were sponsored by manufacturers and enrolled patients at high cardiovascular risk, which matches Ms. Delgado but not all patients with diabetes. Drug costs and coverage vary widely. The patient is invented.

Conclusion

The ADA standards shifted the question from glucose alone to the heart, kidneys and weight, Zinman and colleagues showed that empagliflozin lowers cardiovascular death and heart failure admissions and Marso and colleagues showed that liraglutide reduces major cardiovascular events. Starting an SGLT2 inhibitor now, adding a GLP-1 receptor agonist next, teaching sick-day rules and completing her preventive care give Ms. Delgado treatment chosen for her whole risk profile.

References

American Diabetes Association Professional Practice Committee. (2024). 9. Pharmacologic approaches to glycemic treatment: Standards of care in diabetes-2024. Diabetes Care, 47(Suppl. 1), S158-S178. https://doi.org/10.2337/dc24-S009

Marso, S. P., Daniels, G. H., Brown-Frandsen, K., Kristensen, P., Mann, J. F. E., Nauck, M. A., Nissen, S. E., Pocock, S., Poulter, N. R., Ravn, L. S., Steinberg, W. M., Stockner, M., Zinman, B., Bergenstal, R. M., & Buse, J. B. (2016). Liraglutide and cardiovascular outcomes in type 2 diabetes. New England Journal of Medicine, 375(4), 311-322. https://doi.org/10.1056/NEJMoa1603827

Zinman, B., Wanner, C., Lachin, J. M., Fitchett, D., Bluhmki, E., Hantel, S., Mattheus, M., Devins, T., Johansen, O. E., Woerle, H. J., Broedl, U. C., & Inzucchi, S. E. (2015). Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. New England Journal of Medicine, 373(22), 2117-2128. https://doi.org/10.1056/NEJMoa1504720