Post your answers to the 6 questions corresponding to this week's content on primary care medication management. Provide your responses and rationales. Support your rationales with high-level evidence. (See Post Expectations).

An obese patient, age 45, comes to your office. She recently moved from another state three weeks ago and told you that her FNP diagnosed her with type 2 diabetes mellitus. She is currently not on any medicine for her diabetes, and she wishes to avoid insulin, if possible. She is a non-smoker. Her blood pressure is 138/74 mmHg. Labs from 3-weeks ago was hemoglobin A1C = 8.4%; total cholesterol = 260 mg/dL, triglycerides = 290 mg/dL, HDL = 49 mg/dL, LDL = 170 mg/dL (calculated 10-year ASCVD risk = 6.2%). You discuss current treatment goal recommendations endorsed by the ADA regarding glycemic control, blood pressure control, and lipid management. She agrees to start any medications that you recommend with lifestyle modification and a DASH diet to treat hypertension.

Q1. Which classes of diabetes medications are either weight neutral or cause weight loss? Please give one (1) example of a drug's generic and trade name in that class.

Q2. Based on the current guidelines of the ADA, it would be appropriate to treat her with monotherapy since the patient is hesitant to take any injections. What agent would you recommend? Please provide the trade name, generic name, the dose you would start the patient with frequency, and route.

Q3. What are the contraindications of your selected diabetic therapy?

The patient returns to your office six months later complaining of fatigue for the past two months, constipation, and heavy, irregular menses. Upon examination, you note that her skin is dry, and her fingernails are brittle. You suspect she has hypothyroidism.

Q4. What lab workup should you obtain? What sort of results will you see in patients who have hypothyroidism and hyperthyroidism? 

Q5. What is the treatment of choice for hypothyroidism? What is the mechanism of action? Please provide the initial dose, trade, and generic name of the drug, route, and frequency.

Q6. What are the adverse effects, and what important teaching will you provide this patient on thyroid replacement therapy?