SCENARIO 4 – NURS-6521 Week 4 Assignment Walden University
TF is a 60-year-old male presenting to the clinic for medication refills. Current medications include acetylcholinesterase inhibitor donepezil 5 mg po qhs, anti-amyloid monoclonal antibody lecanemab (Leqembi) 10 mg/kg IV every 2 weeks for early Alzheimer’s disease, and atorvastatin 40 mg po daily. His lab work today includes: fasting BG is 195 mg/dL; HgA1C = 8.5%. Basic Metabolic Profile (BMP) is normal except for Cr 1.9 and eGFR 28. What is his goal A1C? Please SELECT and DISCUSS which of the following would be best to prescribe for TF:
canagliflozin (Invokana) 100 mg PO daily
exenatide (Byetta) 5 mcg SC twice daily
glimepiride 1 mg PO daily
glyburide 2.5 mg PO daily
metformin 500 mg PO daily
semaglutide (Ozempic) 0.25 mg SC once weekly
sitagliptin (Januvia) 50 mg PO daily
SOLVED – Scenario 4:
Diabetes Management in Elderly Male with Alzheimer’s and Renal Impairment
Managing type 2 diabetes in a 60-year-old guy with Alzheimer’s disease and significant renal impairment (eGFR 28 mL/min/1.73m², Stage 4 CKD) requires prioritizing safety and quality of life. The ADA 2025 Standards of Care recommend a relaxed target A1C (e.g., <8.0%). Aggressive control raises hypoglycemia risk, which is especially harmful in cognitively challenged people (difficult to notice symptoms) and connected to dementia. Avoiding hypoglycemia is more important than meeting glycemic objectives. Drug selection must be considered for severe renal impairment and polypharmacy (donepezil, atorvastatin, lecanemab). Some medications are contraindicated, such as Canagliflozin (SGLT2i, eGFR<30), Exenatide (GLP-1 RA, not advised if CrCl<30), and Metformin (eGFR<30, lactic acidosis risk). Sulfonylureas like Glimepiride and Glyburide are unsafe owing to their significant hypoglycemia risk renal impairment (metabolite buildup) and Alzheimer’s. GLP-1 RA semaglutide (Ozempic) is preferable. It has several benefits, including cardiorenal protection, with “26% lower [risk of] major kidney disease events” in T2D and CKD patients compared to non-use (Baser & Lu, 2025). No renal dose adjustment needed; Low intrinsic hypoglycemia risk; A weekly subcutaneous dose may simplify the protocol. If GLP-1 RA is inappropriate because of expense, injectable aversion, or GI irritation, sitagliptin 25 mg daily (dose-adjusted for eGFR<30) is an option. However, it has lower A1C-reducing potency and fewer cardiorenal advantages than semaglutide (Tye et al., 2022). BUY A HUMAN-WRITTEN PAPER HERE Blood glucose (Fasting/PP, SMBG, or CGM to reduce hypoglycemia risk and burden), renal function (eGFR/SCr – critical for all medication decisions), and lipid panel (monitoring atorvastatin efficacy and CV risk) are essential labs and monitoring. Polypharmacy raises serious medication interactions and safety concerns: Donepezil (AChE inhibitor) might aggravate asthma, peptic ulcers, seizures, urinary blockage, and cardiac issues; watch for side effects and cognitive impairments that may hide hypoglycemia. Atorvastatin interacts with grapefruit, antivirals, cyclosporine, fibrates, and antifungals, raising myopathy and ADR risks. Despite no direct DDI with semaglutide, lecanemab has boxed warnings for Amyloid-Related Imaging Abnormalities (ARIA-E, ARIA-H) and intracerebral haemorrhage, especially with anticoagulants. Semaglutide prescription: Pre-filled pen with 0.25 mg/0.5 mL semaglutide (Ozempic). For 4 weeks, inject 0.25 mg subcutaneously weekly, then increase to 0.5 mg. One 2 mg/1.5 mL pen (four 0.25 mg or two 0.5 mg doses), no refills (reassessment after titration). For type 2 diabetes, there is a need to monitor for nausea/vomiting and signs of pancreatitis and educate the patient/caregiver on hypo/hyperglycemia recognition and management. TF is a 60-year-old male presenting to the clinic for medication refills References Agustí, A., Celli, B. R., Criner, G. J., Halpin, D., Anzueto, A., Barnes, P., Bourbeau, J., Han, M. K., Martinez, F. J., De Oca, M. M., Mortimer, K., Papi, A., Pavord, I., Roche, N., Salvi, S., Sin, D. D., Singh, D., Stockley, R., Varela, M. V. L., . . . Vogelmeier, C. F. (2023). Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. American Journal of Respiratory and Critical Care Medicine , 207 (7), 819–837. https://doi.org/10.1164/rccm.202301-0106pp Aroda, V. R., Henry, R. R., Han, J., Huang, W., DeYoung, M. B., Darsow, T., & Hoogwerf, B. J. (2012). Efficacy of GLP-1 receptor agonists and DPP-4 Inhibitors: Meta-Analysis and Systematic Review. Clinical Therapeutics , 34 (6), 1247-1258.e22. https://doi.org/10.1016/j.clinthera.2012.04.013 Carey, R. M., Wright, J. T., Taler, S. J., & Whelton, P. K. (2021). Guideline-Driven management of hypertension. Circulation Research , 128 (7), 827–846. https://doi.org/10.1161/circresaha.121.318083 Gruffydd-Jones, K. (2025). BTS/NICE/SIGN guideline for asthma 2024: Diagnosis, monitoring and chronic asthma management. How does this compare to GINA 2024? Npj Primary Care Respiratory Medicine , 35 (1). https://doi.org/10.1038/s41533-025-00425-x Philis‐Tsimikas, A., Billings, L. K., Busch, R., Portillo, C. M., Sahay, R., Halladin, N., Eggert, S., Begtrup, K., & Harris, S. (2019). Superior efficacy of insulin degludec/liraglutide versus insulin glargine U100 as add‐on to sodium‐glucose co‐transporter‐2 inhibitor therapy: A randomized clinical trial in people with uncontrolled type 2 diabetes. Diabetes Obesity and Metabolism , 21 (6), 1399–1408. https://doi.org/10.1111/dom.13666 Price, D. B., Román-Rodríguez, M., McQueen, R. B., Bosnic-Anticevich, S., Carter, V., Gruffydd-Jones, K., Haughney, J., Henrichsen, S., Hutton, C., Infantino, A., Lavorini, F., Law, L. M., Lisspers, K., Papi, A., Ryan, D., Ställberg, B., Van Der Molen, T., & Chrystyn, H. (2017). Inhaler Errors in the CRITIKAL Study: Type, Frequency, and Association with Asthma Outcomes. The Journal of Allergy and Clinical Immunology in Practice , 5 (4), 1071-1081.e9. https://doi.org/10.1016/j.jaip.2017.01.004 Tye, S. C., De Vries, S. T., Mann, J. F. E., Schechter, M., Mosenzon, O., Denig, P., & Heerspink, H. J. L. (2022). Prediction of the effects of liraglutide on kidney and cardiovascular outcomes based on Short-Term changes in multiple risk markers. Frontiers in Pharmacology , 13 . https://doi.org/10.3389/fphar.2022.786767 Vernieri, F., Iannone, L. F., Lo Castro, F., Sebastianelli, G., De Santis, F., Corrado, M., Marcosano, M., Ornello, R., Grazzi, L., Montisano, D. A., De Cesaris, F., Munafò, A., Fofi, L., Doretti, A., Vaghi, G., Pistoia, F., Ferrandi, D., Battistini, S., Sacco, S., . . . Altamura, C. (2025). Effectiveness and tolerability of atogepant in the prevention of migraine: A real life, prospective, multicentric study (the STAR study). Cephalalgia , 45 (4). https://doi.org/10.1177/03331024251335927 TF is a 60-year-old male presenting to the clinic for medication refills
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