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This month, we profile Kelly Rojas, MS, RN who is currently in the Doctor of Nursing Practice Family Nurse Practitioner program at the Columbia University School of Nursing. Rojas is the co-founder of the Latinx Nurses' Organization, a student ambassador, and a student nurse volunteer for Columbia Student Medical Outreach. In 2023, she completed a clinical rotation in the Dominican Republic where she learned unique ways to provide culturally sensitive, holistic care to patients. Kelly recently participated in a Satellite Media Tour with AANP President Stephen Ferrara to discuss the future of the NP role and her experiences as an NP student as part of National Nurse Practitioners Week this past November.

Q: What experience(s) helped determine your career path? Who is your mentor in the NP field?

Rojas: The adversities I faced as a first-generation, Latina woman led me to pursue a career as a family nurse practitioner. The main adversity that affected my family while I was growing up was the lack of access to routine health care. This ignited a passion in me to bridge the gap between underrepresented populations and equitable access to health care.

The Columbia faculty have been extremely supportive of my career journey throughout the program, and I have been honored to spend time with AANP’s President and the Associate Dean of clinical affairs and assistant professor at Columbia University School of Nursing, Stephen A. Ferrara, DNP, FNP-BC, FAANP, FAAN.

Q: What are the biggest health challenges facing your community?

Rojas: The biggest challenge facing the Latinx community is the lack of access to health care and the ability to navigate the system when access is granted.

"
The lack of access to routine health care ignited a passion in me to bridge the gap between underrepresented populations and equitable access to health care.

Q: How did your experience caring for your uncle with multiple myeloma influence your career course? How did caring for your uncle change the way you cared for your patients?

Rojas: Caring for my uncle opened my eyes to the true importance of advocacy. It allowed me to practice being fully present for the person for whom I was providing care, actively listening to what my uncle understood about his diagnosis, and creating an environment in which he felt comfortable bringing up his concerns. Additionally, the experience taught me to ensure his care plan aligned with his goals. I aspire to do this for all my patients as a student and in the entirety of my career as an NP.

Q: Did you face any difficulty advocating for your uncle’s care?

Rojas: Upon searching for a clinical trial, it was difficult for my uncle to get treatment due to health insurance related issues. We eventually found an amazing hospital that accepted my uncle into its clinical trial. I was so grateful to the NPs who treated my uncle and I was inspired by the phenomenal care he received. The neurology NPs and my uncle’s neurology team at the hospital made us feel like family. I am not yet in clinical practice, but I can assure you that I aim to advocate, prioritize, and care for my patients in the way my uncle’s NPs cared for him.

Q; What unique programs or projects have you participated in to advance patients' health?

Rojas: In 2023, I co-founded Columbia's Latinx Nurses. CLN’s goal is to create and sustain a safe, enriching learning environment for Latinx student nurses and students who wish to know more about the Latinx culture. We aspire to sustain this environment by upholding and practicing cultural humility. We have fostered this by hosting educational events focused on ways to provide holistic culturally sensitive care to the Latinx population.

Q: What aspects of your profession are most rewarding? What aspects of your profession are most challenging?

Rojas: As a first semester NP student, one of my most rewarding experiences was during my clinical rotation at a nursing home. I appreciated the ability to connect with residents and practice building a trusting partnership with patients. Additionally, I found the opportunity to use my clinical strengths and create plans of action that patients felt were both attainable and targeted to meet their needs was profoundly rewarding.

Q: What advice would you give to a young person entering the health care field?


Rojas: Do not lose sight of why you are passionate about choosing your career. If your career entails many years of schooling, learn to love the process every step of the way. Know that you are not alone in your journey, especially if you choose a career in health care. I also think it’s important to join a professional association like AANP. It’s critical to support the advancement of one’s profession, and becoming a student member of a professional organization like AANP is a part of that advancement and strengthening the NP profession.

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Our easy-to-read fact sheets provide clinicians with reliable information to share with patients and their caregivers. 

A predominant risk factor for type 2 diabetes is being overweight or obese, so weight loss goals while maintaining normal blood sugar levels are very important for some patients. In addition to lifestyle modifications, medications for type 2 diabetes may aid in losing weight.1,2

Obesity

Obesity is defined as a body mass index (BMI) of 30 kg/m2 or higher and is associated with many major health issues including cardiovascular disease, osteoarthritis, and type 2 diabetes. A weight loss of 5% to 15% can improve obesity-related complications.1,2

There are approved medications to help treat obesity, including phentermine (Lomaira®), orlistat (Alli®), topiramate (Trokendi XR®), and naltrexone/bupropion (Contrave®). However, these are not indicated to treat type 2 diabetes.3

Type 2 Diabetes

Type 2 diabetes is a chronic disease due to a progressive loss of insulin secretion and/or increased insulin resistance. As a result, the body’s naturally produced insulin becomes less effective in reducing the amount of sugar in your blood. Excess weight or excess percentage of body fat can cause some degree of insulin resistance. Most, but not all, patients with type 2 diabetes have overweight or obesity.

Different antidiabetic medications work through different mechanisms to help lower blood sugar. Some of these medications also provide additional benefits for patients, including weight loss. The medications with weight loss benefits include metformin, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists.2

Type 2 Diabetes Medications That Induce Weight Loss

The following is a list of FDA-approved medications for the management of type 2 diabetes that may also result in weight loss. It is important to note that the amount of weight loss can vary depending on the medication, dose, duration of therapy, and lifestyle changes. Speak with your provider to know additional information.

Drug ClassHow It Works Side Effects
Biguanide
Metformin 
Decreases glucose production by the liver and improves insulin sensitivity4Nausea  Vomiting Diarrhea  Constipation Stomach pain Bloating Altered taste,7,8
SGLT2 Inhibitors   Canagliflozin (Invokana®)   Dapagliflozin (Farxiga®)   Empagliflozin (Jardiance®)Reduces reabsorption of filtered sugar and increases urinary glucose excretion9Increased urination Urinary tract infection (UTI) Female genital infection13
GLP-1 Receptor Agonists   Dulaglutide (Trulicity®)   Exenatide
(Byetta®; BYDUREON BCise®)   Liraglutide (Victoza®)   Semaglutide (Rybelsus®; Ozempic®)   Tirzepatide (Mounjaro®)
Simulates GLP-1 receptors to increase insulin secretion and decrease glucagon secretion14Nausea  Vomiting Diarrhea Acute kidney injury Injection site reactions24

Weight Loss Differences 

Biguanides

In a long-term study, patients who took metformin maintained an average weight loss of 6.2% between 6 and 15 years of treatment. Patients who experienced greater long-term weight loss were those who (1) lost more weight during their first year of treatment, and (2) were older in age.5,6

SGLT2 Inhibitors

Various studies demonstrate long-term weight loss effects among patients taking SGLT2 inhibitors. In an analysis of multiple studies, patients had an average weight loss of between 1.5 kg and 2 kg after 4 years of treatment. These effects increased with increasing doses of these medications. Other studies have revealed average weight loss percentages between 2.2% and 3.3% of patients’ starting weight.5, 10-12

Other studies show improved weight loss among patients combining SGLT2 inhibitors with other drugs, such as metformin or GLP-1 receptor agonists. SGLT2 inhibitors may therefore be the drug of choice for patients also with heart and kidney disease.22,23 However, low blood sugar is more likely to occur when they are used as add-ons rather than used alone.30

GLP-1 Receptor Agonists

Studies report a wide range of weight loss effects associated with GLP-1 receptor agonists, from 1 kg to 15 kg depending on the medication.15-21 Weight loss effects depend on dose and treatment durations.5

Like SLGT2 inhibitors, GLP-1 receptor agonists can be used as add-on therapies for patients with heart and kidney disease, but low blood sugar is more likely to occur. 22, 23, 30   

Frequently Asked Questions

Can I eat anything I want while on these medications?

No, food choices still play a significant role in diabetes management.

Different types of diets for patients with diabetes include Mediterranean, low-fat, low-carb, vegetarian, and vegan diets. Additionally, the Dietary Approaches to Stop Hypertension (DASH) approach could prevent more serious complications such as heart or kidney disease among those who have or are at risk for high blood pressure and high cholesterol.22,23

Diet modifications can also enhance natural GLP-1 and insulin production/sensitivity and prevent escalation of antidiabetic therapies while satisfying nutritional needs.24

Do I still have to exercise while on these medications?

Yes, it is recommended to engage in physical activity regularly, even if on medications that can result in weight loss, to prevent development and progression of heart- and kidney-related complications.

Patients with type 2 diabetes are advised to do 150 minutes per week of moderate to vigorous exercise or 75 minutes per week of high intensity exercise over a course of 3 or more days per week.25 Studies report that physical activity can contribute to increased effectiveness of certain medications, including GLP-1 receptor agonists and metformin.25-27

How can I prevent side effects such as nausea, vomiting, diarrhea, bloating, and constipation?

Metformin can cause an upset stomach on initial treatment so it should be taken with food. Note that these side effects should go away over time, so do not skip doses or stop taking metformin without speaking with your provider.7,8

The initial dose of a GLP-1 receptor agonist or SGLT2 inhibitor is typically low to prevent stomach issues but not high enough to help manage your blood sugar. For this reason, your provider may start you on a higher dose, but you should let them know if the stomach side effects become unmanageable for you.28,29

Can I be on multiple of these medications at the same time?

Yes, GLP-1 receptor agonists and/or SGLT2 inhibitors are preferred over other drug classes as add-on treatments to metformin, especially for patients at risk for heart or kidney disease, according to the American Association of Clinical Endocrinology and American Diabetes Association guidelines.

Before adding these medications, your doctor may consider factors such as heart and kidney disease, potential weight loss, and potential adverse effects.22,23 The use of GLP-1 receptor agonists with metformin may also exacerbate diarrhea.29

Click here for PDF

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As the global population becomes older, physicians are increasingly navigating the complexities of geriatric medicine. Older adults often have multiple chronic conditions that require ongoing treatment, which frequently results in the practice of polypharmacy — typically defined as the concurrent use of 5 or more medications.1

Although polypharmacy begins as a well-intentioned effort to manage cooccurring conditions, the interaction of these different medications can become a health hazard instead of an optimal solution. Given the increased risks for adverse drug interactions, medication errors, and cognitive impairment, addressing polypharmacy and developing a nuanced approach to geriatric care is crucial to safeguarding the health of older adults.

Increasing Prevalence of Polypharmacy in Older Adults

In a chapter on polypharmacy published in Geriatric Rehabilitation, co-authors Parulekar and Rogers noted that while only 13% of the United States population was aged 65 years and older, this age group accounted for 33% of total prescription medications.2 More than 50% of older adults with multimorbid conditions receive 5 or more medications, with the rate varying between 10% and 55% globally.3 Furthermore, a study of survey data from the Centers for Disease Control and Prevention (CDC) found that the majority of older adults in the US had major polypharmacy and nonsteroidal anti-inflammatory drugs (NSAIDs) were the most common medication type.4

The prevalence of polypharmacy is even higher among women. Research suggests that women are more likely than men to require more than 1 or more specialized medications,1 and older women have higher rates of multimorbidity relative to men — with a consequently higher prevalence of polypharmacy.5

"
Managing polypharmacy requires careful monitoring and coordination by health care providers to deprescribe, optimize medication regimens, and minimize risks for patients.

Erika Ramsdale, MD, an associate professor at the Department of Medicine, Hematology/Oncology at the University of Rochester Medicine, has studied the effects of polypharmacy on older adults initiating cancer treatment6 and spoke about this issue. “Polypharmacy and potentially inappropriate medications are very, very common in older adults, and especially within certain populations, such as older adults with cancer. [However], there is not an easy way to estimate the burden of medication-related adverse effects on patients and the health care system as a whole,” she remarked.

Risk factors for polypharmacy include both patient-level factors (eg, increased age, difficulty self-managing medications, multimorbidity, disabilities) as well as health care system-level components, such as poor continuity of care, prescribing cascades, the use of multiple pharmacies, and inadequately updated medical records.7,8

While polypharmacy is often deemed necessary to treat multimorbidity, the concurrent use of medications has been shown to cause harm in and of itself. In a retrospective cohort study published in 2023, older adults who received multiple medications experienced significantly higher rates of severe comorbidity relative to those who did not experience polypharmacy. Patients with polypharmacy also had a greater rate of all-cause hospitalizations and emergency department (ED) visits.9

Polypharmacy also carries specific neurologic and psychiatric risks. Older adults with polypharmacy and multimorbidity demonstrate greater levels of cognitive impairment, relative to their peers with fewer comorbidities and medications,10 and has been associated with worse self-reported health and depression in older adults.11

Given the risks associated with multiple medications in older adults, many experts have called into question the “appropriate” vs “inappropriate” use of polypharmacy.2 To this aim, Mohamed and colleagues conducted a study to examine the associations between polypharmacy, potentially inappropriate medications, and adverse treatment outcomes in a large national cohort of older adults with advanced cancer. They found that 67% of patients received 1 or more inappropriate medications, and the use of inappropriate medications increased the odds of unplanned treatment-related hospitalization. Additionally, polypharmacy overall was associated with increased risk for postoperative complications, hospitalizations, and mortality risk.8

Dr Ramsdale emphasized the importance of not just the number of medications prescribed to a patient, but also their appropriateness. “Some patients have polypharmacy by number, but all their medications are needed and appropriate.”

Further complicating this medication management issue, Dr Ramsdale addressed the challenge of differentiating between patients who develop symptoms from polypharmacy vs a root cause issue, such as comorbidities/disease. “Often, there is not one ‘root cause’ for a symptom or adverse effect in older adults. There are generally multiple contributing factors and you have to look at all of them and also how the factors interact with each other. One thing you can say is that medications are very often contributing and need to be considered each time something happens.”

Concerns & Barriers in the Management of Polypharmacy in Clinical Practice

Although a wealth of evidence has demonstrated the adverse health risks associated with polypharmacy, the question remains as to how health care systems should best manage this issue. Researchers conducted a study across 14 countries, including the US and UK, to identify the barriers associated with addressing polypharmacy in primary care. They found the most common barriers were a lack of evidence-based guidance, a lack of communication and decision-making systems, and gaps in support.12

From a clinician’s perspective, Dr Ramsdale stated,

Older adults tend to have many doctors who are all prescribing [medications], sometimes in different health systems, leading to fragmentation of care. Providers also may not want to alter [a medication] that another provider has prescribed.

In-depth review of medications takes a lot of time and thought, as each patient’s situation is unique and everyone has different goals and preferences. In addition, clinicians often do not have the time or resources to accomplish this for all patients because of the way our health care system is set up and [the type] of care it prioritizes.

Because one of the major concerns regarding polypharmacy is the increased risk for drug-to-drug interactions that are associated with adverse events and even death,13 there is a critical need to support physicians in these complicated — but increasingly common — cases of medication management.

How Can Providers Manage Polypharmacy in Older Adults?

Researchers have agreed that screening and interventional tools to optimize medication usage for improved outcomes may be beneficial.9 However, the frequency of prescribing multiple medications needs to be evaluated to reduce adverse events and medication burden in this patient population.4 Clinical studies have shown that one of the ways of reducing exposure to polypharmacy is through the practice of “deprescribing” medications.12

Deprescribing medications involves the identification of inappropriate or unnecessary medications to ultimately taper or discontinue their use. In 2019, the American Academy of Family Physicians (AAFP) developed recommendations for clinicians to help in deprescribing medications and reducing the risks for polypharmacy.7 Some of the key guidelines include the identification and prioritization of medications to discontinue, conducting informed decision-making with the patient, ensuring routine follow-up visits, and considering the risks vs benefits when refilling medications.

“Patients and their caregivers can be excellent advocates. All older adults should be [encouraged to] ask questions about the [safety] of their medications. The US Deprescribing Research Network and the Canadian Medication Appropriateness and Deprescribing Network have excellent patient resources available,” Dr Ramsdale recommended.

One of the key aspects in reducing polypharmacy is medication reconciliation, which can be more effectively achieved by improving the communication between provider and patient and the process of discharge from hospitalization. With the increased use of artificial intelligence and clinical decision support systems, the risks for polypharmacy may be minimized.14

Given that many older patients experience some degree of polypharmacy, pharmacists, specialist nurses, and physician assistants play a vital role in medication management, quality prescribing practices, and safety monitoring.4 Managing polypharmacy requires careful monitoring and coordination by health care providers to deprescribe, optimize medication regimens, and minimize risks for patients. Overall, polypharmacy in older adults is directly related to health care service outcomes,9 which warrants the need for a multidisciplinary, holistic approach to address and evaluate its use among patients.

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A 26-year-old Black man is referred for evaluation of a skin condition affecting his underarms and groin that has waxed and waned in intensity over the past 5 years. A female cousin is similarly affected. He has had several sites treated surgically and one boil recently drained. He complains of pain and malodor. Current medications are doxycycline and mirtazapine. Examination of the affected areas reveal scattered abscesses, sinus tracks, and hypertrophic scars.

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