WEBVTT 00:00:00.299 --> 00:00:01.899 The blood sugar number looks good. 00:00:02.176 --> 00:00:03.691 The visit still is not finished. 00:00:03.968 --> 00:00:06.485 What might we miss if that number is where we stop? 00:00:06.827 --> 00:00:09.319 Welcome to HEART RESERVE Clinical Conversations. 00:00:09.636 --> 00:00:13.305 I’m Lisa Zahakos, a physician assistant and founder of HEART RESERVE. 00:00:13.646 --> 00:00:18.596 In this episode, we’ll follow Maya after gestational diabetes, Elena during obesity 00:00:18.724 --> 00:00:21.997 and diabetes treatment, and Nora as she plans a pregnancy. 00:00:22.284 --> 00:00:24.545 These are fictional teaching cases for clinicians. 00:00:24.801 --> 00:00:27.575 You can listen straight through, or use the chapters to return to 00:00:27.617 --> 00:00:30.604 a case. I’ll ask you to consider a few decisions and then 00:00:30.647 --> 00:00:34.982 walk through the reasoning. The activity page has the objectives, references and 00:00:35.024 --> 00:00:37.791 online questions. Let’s begin with Maya. 00:00:38.026 --> 00:00:41.183 Case 1 Complete postpartum testing and continuing care. 00:00:41.482 --> 00:00:44.618 Maya is seven weeks postpartum after gestational diabetes. 00:00:44.810 --> 00:00:48.138 She feels well, but the recommended glucose test has not happened. 00:00:48.565 --> 00:00:51.733 Timing. Case information: 7 weeks postpartum. 00:00:51.967 --> 00:00:56.767 History. Case information: Gestational diabetes. Current concern. 00:00:57.045 --> 00:01:00.565 Case information: Missed glucose test. Practical barrier. 00:01:00.757 --> 00:01:03.661 Case information: Childcare and a fasting visit. 00:01:03.963 --> 00:01:07.547 Neither the obstetric nor primary care office has arranged Maya’s test. 00:01:07.761 --> 00:01:11.345 Her recent A one C is 5.4 percent, and she has no 00:01:11.430 --> 00:01:14.194 hyperglycemic symptoms. What should happen now? 00:01:14.441 --> 00:01:17.683 Which plan best evaluates her glucose status at this point? 00:01:17.939 --> 00:01:20.475 Pause here if you would like to consider your next step. 00:01:20.793 --> 00:01:25.486 The American Diabetes Association recommends a 75 gram oral glucose tolerance test 00:01:25.699 --> 00:01:29.262 at 4 to 12 weeks after a pregnancy with gestational diabetes. 00:01:29.539 --> 00:01:31.810 The order also needs a workable completion plan. 00:01:32.117 --> 00:01:36.789 Confirm fasting instructions, an achievable laboratory appointment and a result reviewer. 00:01:37.109 --> 00:01:40.608 Ask what would make the visit possible; another order alone will not 00:01:40.651 --> 00:01:44.647 resolve her childcare barrier. Turn the order into a completed assessment. 00:01:44.932 --> 00:01:48.729 Primary care accepts responsibility for the test and result and confirms the 00:01:48.772 --> 00:01:53.223 handoff with obstetrics. If the oral glucose tolerance test cannot be completed, 00:01:53.458 --> 00:01:57.469 document the barrier and arrange clinician review of an alternative pathway. 00:01:57.938 --> 00:02:02.247 Teach-back: “This test checks fasting glucose and the response two hours after 00:02:02.418 --> 00:02:06.393 a glucose drink. How will you prepare, and who will contact you?” 00:02:06.621 --> 00:02:09.650 Document which office will act if the appointment is missed. 00:02:09.992 --> 00:02:13.661 The office books an early appointment and confirms childcare and result communication 00:02:13.789 --> 00:02:18.548 with Maya. Maya’s oral glucose tolerance test is normal by nonpregnancy criteria. 00:02:18.889 --> 00:02:22.409 She asks whether gestational diabetes can now be removed from her history. 00:02:22.772 --> 00:02:24.404 What belongs in the ongoing plan? 00:02:24.670 --> 00:02:27.294 Pause here if you would like to consider your next step. 00:02:27.785 --> 00:02:31.860 Preserve the history and plan lifelong screening at 1 to 3-year intervals, 00:02:32.094 --> 00:02:37.582 adjusted to clinical context. Record the reassuring result, ongoing screening interval and 00:02:37.625 --> 00:02:41.422 responsible clinician. Make the result useful to the next clinician. 00:02:41.763 --> 00:02:46.741 Prediabetes or diabetes results need the appropriate diagnostic and management pathway. 00:02:46.983 --> 00:02:50.973 New symptoms or pregnancy warrant assessment without waiting for the routine interval. 00:02:51.335 --> 00:02:56.199 Record prior gestational diabetes separately from current diabetes, including pregnancy year and 00:02:56.242 --> 00:03:01.168 postpartum result. Pregnancy history informs prevention; it is not proof of coronary 00:03:01.254 --> 00:03:06.886 disease. Review other adverse pregnancy outcomes, blood pressure, smoking, indicated lipid testing 00:03:07.099 --> 00:03:11.259 and overall cardiovascular health. Maya and her clinician record the next screening 00:03:11.344 --> 00:03:14.182 date and retain gestational diabetes in her history. 00:03:14.630 --> 00:03:16.699 Postpartum testing and the next action. 00:03:17.062 --> 00:03:21.084 Maya skips breakfast and avoids most carbohydrate because she fears diabetes. 00:03:21.352 --> 00:03:25.064 She is breastfeeding, has a limited grocery budget and wants enough energy 00:03:25.235 --> 00:03:27.809 for her day. Which referral is most useful? 00:03:28.122 --> 00:03:31.834 The referral should specify the clinical question and the practical circumstances the 00:03:31.877 --> 00:03:35.906 registered dietitian needs to address. Ask what she usually eats, which foods 00:03:35.981 --> 00:03:39.777 she avoids and why. Build the plan around familiar, affordable foods. 00:03:40.000 --> 00:03:42.454 Write a nutrition referral with a clinical question. 00:03:42.816 --> 00:03:48.448 Send the registered dietitian the lactation context, meal skipping, carbohydrate fear, access 00:03:48.704 --> 00:03:52.782 concerns and energy goal. Request an adequacy assessment and return of the 00:03:52.824 --> 00:03:57.176 agreed plan. If food access limits the plan, identify a usable community 00:03:57.390 --> 00:04:01.443 resource. The referring office checks visit completion and follows up if it 00:04:01.486 --> 00:04:06.289 is missed. Individualize medical nutrition therapy; this case does not prescribe a 00:04:06.332 --> 00:04:11.384 universal postpartum diet. The referral includes Maya’s normal oral glucose tolerance test, 00:04:11.576 --> 00:04:16.354 lactation, nutrition concerns and how recommendations will return to primary care. 00:04:16.738 --> 00:04:20.950 Before the handoff. Document the completed postpartum test and interpretation. 00:04:21.322 --> 00:04:24.607 Record the ongoing screening interval and responsible clinician. 00:04:24.948 --> 00:04:29.336 Send the registered dietitian the specific nutrition question and relevant circumstances. 00:04:29.755 --> 00:04:32.913 Confirm how Maya will receive results and what happens after a missed 00:04:33.041 --> 00:04:37.589 appointment. Now meet Elena. Her clinical history changes the treatment question. 00:04:37.888 --> 00:04:41.515 Case 2 Connect cardiovascular benefit with nutrition and function. 00:04:41.856 --> 00:04:45.949 Elena has obesity, type 2 diabetes, and a prior myocardial infarction. 00:04:46.203 --> 00:04:49.317 Her A one C is at her individualized goal, but the treatment 00:04:49.360 --> 00:04:51.643 review is not complete. A one C. 00:04:51.963 --> 00:04:55.909 Case information: 6.7 percent. body mass index. 00:04:56.229 --> 00:04:59.387 Case information: 33 kilograms per square meter. 00:04:59.685 --> 00:05:04.965 Current disease. Case information: Type 2 diabetes and prior myocardial infarction. 00:05:05.328 --> 00:05:09.562 Pregnancy history. Case information: Preeclampsia in her 30s. 00:05:09.773 --> 00:05:14.489 Elena takes metformin and secondary-prevention medicines after a myocardial infarction three years 00:05:14.616 --> 00:05:17.854 ago. She is postmenopausal and has no acute symptoms. 00:05:18.060 --> 00:05:21.724 A colleague proposes waiting for A one C to rise before reviewing 00:05:21.851 --> 00:05:25.707 additional diabetes therapy. What is the best next treatment discussion? 00:05:25.984 --> 00:05:28.386 Pause here if you would like to consider your next step. 00:05:28.611 --> 00:05:34.371 In type 2 diabetes with established atherosclerotic cardiovascular disease, cardiovascular benefit can 00:05:34.414 --> 00:05:37.838 guide treatment independently of the need for additional glucose lowering. 00:05:38.148 --> 00:05:42.585 Her myocardial infarction establishes atherosclerotic cardiovascular disease. 00:05:42.927 --> 00:05:47.151 Review the rest of secondary prevention, kidney status, symptoms and access. 00:05:47.535 --> 00:05:50.742 Drug choice should follow relevant population and outcome evidence. 00:05:51.090 --> 00:05:55.485 Separate the treatment goals. Document the cardiovascular goal so an at-goal A 00:05:55.528 --> 00:05:58.762 one C is not mistaken for absence of a treatment rationale. 00:05:59.052 --> 00:06:06.050 Compare options by disease, outcome, contraindications, tolerability, affordability and preference. 00:06:06.434 --> 00:06:09.407 heart failure or chronic kidney disease may change the choice. 00:06:09.735 --> 00:06:15.473 Keep nutrition, activity, behavioral support and other appropriate obesity treatments in view. 00:06:15.921 --> 00:06:18.524 This is not a complete obesity-treatment algorithm. 00:06:18.780 --> 00:06:22.650 The evidence separates weight, glycemic and cardiovascular findings. 00:06:22.979 --> 00:06:26.776 Do not infer superior cardiovascular protection from greater weight loss. 00:06:27.075 --> 00:06:30.761 Agree which clinician will review metabolic and cardiovascular response. 00:06:31.161 --> 00:06:34.916 Compare suitable options with Elena and document the treatment goal and follow-up 00:06:34.959 --> 00:06:37.796 owner. From trial evidence to a treatment choice. 00:06:38.159 --> 00:06:41.202 Elena asks whether more weight loss means better heart protection. 00:06:41.515 --> 00:06:46.613 Check the population, comparator, endpoint, effect and safety findings before answering. 00:06:47.061 --> 00:06:52.053 SELECT Established cardiovascular disease, age at least 45, body mass index at 00:06:52.096 --> 00:06:58.510 least 27, no diabetes. What was demonstrated: Semaglutide 2.4 milligrams weekly versus 00:06:58.724 --> 00:07:04.932 placebo reduced first major adverse cardiovascular events: 6.5 percent versus 8.0 percent; 00:07:05.124 --> 00:07:12.100 hazard ratio 0.80, 95 percent confidence interval 0.72 to 0.90. 00:07:12.484 --> 00:07:16.849 Boundary for the decision: Applies to a defined secondary-prevention population. 00:07:17.204 --> 00:07:21.044 It does not directly answer Elena’s diabetes question or show benefit after 00:07:21.214 --> 00:07:27.444 gestational diabetes alone. SURPASS CVOT Type 2 diabetes and established atherosclerotic cardiovascular 00:07:27.572 --> 00:07:34.122 disease. What was demonstrated: Tirzepatide versus dulaglutide met noninferiority for cardiovascular death, 00:07:34.335 --> 00:07:41.717 myocardial infarction or stroke: hazard ratio 0.92, 95.3 percent confidence interval 0.83 00:07:41.923 --> 00:07:45.841 to 1.01. Superiority was not established. 00:07:46.140 --> 00:07:50.065 Boundary for the decision: An active comparator with established benefit is not 00:07:50.151 --> 00:07:54.347 placebo. Do not describe greater weight loss as proven superiority for major 00:07:54.518 --> 00:07:59.714 adverse cardiovascular events. SUMMIT Obesity and heart failure with preserved ejection fraction. 00:08:00.088 --> 00:08:04.781 What was demonstrated: Tirzepatide improved the composite of cardiovascular death or worsening 00:08:04.824 --> 00:08:07.570 heart failure versus placebo and health status. 00:08:07.841 --> 00:08:12.364 Boundary for the decision: The composite does not establish reduced cardiovascular death 00:08:12.492 --> 00:08:17.142 alone. Confirm heart failure with preserved ejection fraction rather than diagnosing it 00:08:17.185 --> 00:08:19.373 from body mass index and breathlessness. 00:08:19.642 --> 00:08:23.098 STEP H F peff enrolled adults with body mass index at least 00:08:23.226 --> 00:08:28.431 30, symptomatic heart failure, left ventricular ejection fraction at least 45 percent, 00:08:28.644 --> 00:08:35.487 and no diabetes. What was demonstrated: Semaglutide improved symptoms, physical limitations and 00:08:35.572 --> 00:08:40.333 exercise function. Boundary for the decision: Patient-reported health status and physical function 00:08:40.547 --> 00:08:43.875 matter, but are not interchangeable with a mortality endpoint. 00:08:44.301 --> 00:08:48.278 These trials cannot be ranked directly across different populations and methods. 00:08:48.585 --> 00:08:54.431 Discuss benefit with tolerability: SELECT reported adverse-event discontinuation in 16.6 percent with 00:08:54.473 --> 00:08:57.524 semaglutide versus 8.2 percent with placebo. 00:08:57.844 --> 00:08:59.836 Choose the branch that matches the disease. 00:09:00.381 --> 00:09:04.585 Elena’s myocardial infarction and diabetes guide the evidence choice. 00:09:04.822 --> 00:09:08.662 If heart failure or chronic kidney disease is present, review the relevant 00:09:08.833 --> 00:09:13.269 S G L T 2 evidence and indications; incretin therapy does not 00:09:13.313 --> 00:09:15.603 replace the rest of cardiac or kidney care. 00:09:15.845 --> 00:09:21.220 FINEARTS H F provides a separate example: finerenone reduced total worsening-heart failure 00:09:21.306 --> 00:09:25.316 events and cardiovascular death as a composite in patients with left ventricular 00:09:25.445 --> 00:09:27.780 ejection fraction at least 40 percent. 00:09:28.153 --> 00:09:34.040 It is not an obesity medicine; selection requires indication, kidney, potassium, interaction 00:09:34.297 --> 00:09:38.000 and label review. Disease status determines which evidence applies. 00:09:38.332 --> 00:09:42.705 Find the relevant disease pathway, then check its trial population and endpoint. 00:09:43.068 --> 00:09:44.748 More than one pathway may apply. 00:09:45.021 --> 00:09:49.500 Compare Elena’s established disease with Maya’s pregnancy history; do not assume their 00:09:49.543 --> 00:09:53.843 trial evidence is interchangeable. In a separate variation, Elena asks whether a 00:09:53.886 --> 00:09:59.091 report about oral orforglipron has established superior cardiovascular protection in diabetes. 00:09:59.304 --> 00:10:04.411 What should guide the response? The July 2026 Foundayo label lists chronic 00:10:04.497 --> 00:10:09.297 weight management, not a diabetes-treatment or cardiovascular risk-reduction indication. 00:10:09.617 --> 00:10:12.570 Route of administration does not establish those outcomes. 00:10:12.919 --> 00:10:19.660 ACHIEVE-4’s September 30 sponsor report compared orforglipron with insulin glargine in 2,749 00:10:19.746 --> 00:10:24.424 adults with type 2 diabetes, body mass index at least 25 and 00:10:24.467 --> 00:10:30.853 increased cardiovascular risk. four component major adverse cardiovascular events hazard ratio 0.84 00:10:30.897 --> 00:10:38.030 (95 percent confidence interval 0.59 to 1.20) met noninferiority, not superiority. 00:10:38.295 --> 00:10:43.857 Mortality analyses lacked family-wise type I error control; ATTAIN-OUTCOMES was ongoing. 00:10:44.171 --> 00:10:48.864 Review the full label for an eligible weight-management patient: GI effects, medullary 00:10:48.992 --> 00:10:56.021 thyroid carcinoma or multiple endocrine neoplasia type 2 and hypersensitivity contraindications, dehydration, 00:10:56.393 --> 00:11:02.226 hypoglycemia with insulin/secretagogues, and C Y P 3 A 4/O A T 00:11:02.226 --> 00:11:05.417 P 1 B and simvastatin interactions. 00:11:06.036 --> 00:11:09.278 Concomitant use with another G L P 1 receptor agonist is not 00:11:09.321 --> 00:11:13.088 recommended. Emerging therapy and the question still unanswered. 00:11:13.558 --> 00:11:18.668 Retatrutide remained investigational in the September 2026 TRIUMPH-2 sponsor report. 00:11:19.043 --> 00:11:23.522 Weight and A one C findings do not establish approval, reproductive safety 00:11:23.779 --> 00:11:28.954 or cardiovascular event reduction. This activity makes no prescribing or enrollment recommendation. 00:11:29.181 --> 00:11:34.002 At follow-up, Elena reports weight loss, nausea, small meals, constipation and less 00:11:34.087 --> 00:11:37.927 energy. She can drink and has no persistent vomiting or severe abdominal 00:11:38.013 --> 00:11:40.029 pain. A dose increase is approaching. 00:11:40.296 --> 00:11:43.603 Which response best addresses the information she has just shared? 00:11:43.923 --> 00:11:46.374 Pause here if you would like to consider your next step. 00:11:46.648 --> 00:11:51.299 Review the whole treatment response, including symptoms and nutrition, before the prescriber 00:11:51.427 --> 00:11:55.736 decides on dose progression. Assess what she can eat and drink, symptom-related 00:11:55.950 --> 00:12:00.576 avoidance and daily function. Nutrition review should accompany treatment, before a problem 00:12:00.747 --> 00:12:04.651 becomes severe. Review symptoms before deciding the next dose. 00:12:04.928 --> 00:12:10.560 Review intake, fluids, bowel habits, activity, dose history and other medicines; consider 00:12:10.688 --> 00:12:15.397 other causes. The prescriber decides the medication plan; the registered dietitian assesses 00:12:15.568 --> 00:12:21.285 intake and communicates concerns. Persistent vomiting, inability to maintain fluids or severe 00:12:21.414 --> 00:12:24.154 persistent abdominal pain warrants prompt assessment. 00:12:24.462 --> 00:12:26.915 These examples are not an exhaustive triage rule. 00:12:27.107 --> 00:12:29.625 Give Elena a contact route if symptoms worsen. 00:12:29.881 --> 00:12:33.848 The team reviews symptoms and intake before escalation and explains when to 00:12:33.891 --> 00:12:38.386 seek prompt assessment. After prescriber review, Elena’s symptoms improve. 00:12:38.728 --> 00:12:42.098 She wants to preserve strength but has knee pain and little resistance-exercise 00:12:42.397 --> 00:12:45.725 experience. She asks about a protein target seen online. 00:12:46.066 --> 00:12:47.866 Which approach best fits her goals? 00:12:48.172 --> 00:12:52.566 Nutrition and appropriate strength activity should be planned together, adapted to capability 00:12:52.823 --> 00:12:57.635 and health status. Adapt nutrition and resistance activity to capability and health 00:12:57.763 --> 00:13:01.689 status; consider rehabilitation or physical therapy when needed. 00:13:02.158 --> 00:13:04.028 Measure a goal that matters to Elena. 00:13:04.277 --> 00:13:07.818 Choose a meaningful task, such as rising from a chair, and reassess 00:13:07.904 --> 00:13:13.237 consistently. Worsening function needs evaluation. State the limitation and functional goal in 00:13:13.280 --> 00:13:19.219 a referral. Reassess intake, symptoms, function, affordability and acceptability. 00:13:19.667 --> 00:13:22.013 This plan does not guarantee muscle preservation. 00:13:22.440 --> 00:13:26.430 Weight loss or a lean-mass estimate alone does not diagnose sarcopenia. 00:13:26.960 --> 00:13:31.312 Elena chooses a feasible nutrition change and suitable activity, with function included 00:13:31.354 --> 00:13:36.221 in follow-up. Before the handoff. State whether the patient has established atherosclerotic 00:13:36.264 --> 00:13:39.570 cardiovascular disease, heart failure, or kidney disease. 00:13:39.890 --> 00:13:43.934 Document the treatment goal, relevant outcome evidence, and patient preference. 00:13:44.309 --> 00:13:47.594 Connect the nutrition assessment to symptoms and medication decisions. 00:13:47.978 --> 00:13:51.128 Choose a follow-up measure that includes how the patient functions. 00:13:51.672 --> 00:13:54.850 Our third case brings reproductive planning into the treatment visit. 00:13:55.042 --> 00:13:58.242 Case 3 Plan treatment around reproductive goals. 00:13:58.584 --> 00:14:01.314 Nora takes injectable semaglutide for obesity. 00:14:01.527 --> 00:14:03.703 She would like to try for pregnancy in three months and wants 00:14:03.789 --> 00:14:05.282 to know what should happen before then. 00:14:05.538 --> 00:14:10.231 Medication. Case information: Semaglutide injection. Product and reason. 00:14:10.530 --> 00:14:14.315 Case information: Wegovy for obesity. Pregnancy intention. 00:14:14.601 --> 00:14:16.969 Case information: Try in 3 months. 00:14:17.332 --> 00:14:23.561 Diabetes. Case information: Not diagnosed. Nora uses contraception and is not pregnant. 00:14:23.860 --> 00:14:27.877 She asks which stopping interval applies to her injectable semaglutide. 00:14:28.140 --> 00:14:31.190 Which guidance fits the product and indication in this case? 00:14:31.510 --> 00:14:33.836 Pause here if you would like to consider your next step. 00:14:34.284 --> 00:14:37.868 The current Wegovy labeling specifies at least two months before planned pregnancy 00:14:37.953 --> 00:14:43.202 for weight reduction. Confirm the product, formulation, indication and reproductive goal. 00:14:43.480 --> 00:14:48.130 Integrate medication timing with nutrition, other medicines and preconception care. 00:14:48.429 --> 00:14:52.249 Make the dates understandable. The weekly dosing schedule does not determine the 00:14:52.292 --> 00:14:56.900 pregnancy stopping interval. For a January 15 intended conception date, a last 00:14:57.028 --> 00:15:00.366 dose no later than November 15 illustrates two months. 00:15:00.717 --> 00:15:03.704 Individual review may support earlier discontinuation. 00:15:04.088 --> 00:15:06.584 Use teach-back and discuss changed plans. 00:15:06.989 --> 00:15:10.232 Do not make reproductive care conditional on an arbitrary weight. 00:15:10.445 --> 00:15:13.545 Respect the patient’s contraceptive and pregnancy choices. 00:15:13.915 --> 00:15:17.584 Nora and her prescriber document the dates and arrange preconception care and 00:15:17.627 --> 00:15:22.896 nutrition support. Consider a separate variation: Nora is taking tirzepatide as Zepbound, 00:15:23.088 --> 00:15:26.854 uses an oral hormonal contraceptive, and does not want pregnancy. 00:15:27.121 --> 00:15:29.318 Her prescriber is increasing the dose. 00:15:29.851 --> 00:15:32.902 She asks whether taking the pill at a different time is enough. 00:15:33.350 --> 00:15:36.073 What counseling is supported by the current Zepbound label? 00:15:36.363 --> 00:15:40.502 Discuss a patient-chosen non-oral method or an added barrier method for the 00:15:40.545 --> 00:15:46.462 specified four-week periods. Explain the product-specific issue, discuss feasible options and confirm 00:15:46.548 --> 00:15:49.748 understanding without prescribing a particular contraceptive choice. 00:15:50.046 --> 00:15:54.420 Give a usable contraception instruction. This is a separate Zepbound variation, not 00:15:54.463 --> 00:15:57.428 a recommended switch. Confirm the contraception route. 00:15:57.663 --> 00:16:02.306 An October 20 escalation starts a four-week precaution through November 17. 00:16:02.598 --> 00:16:04.945 Each further escalation starts another period. 00:16:05.414 --> 00:16:08.059 Record the dates and chosen method in the dose-review plan. 00:16:08.230 --> 00:16:13.419 Oral formulations differ. Oral Wegovy requires morning dosing fasting, with no more 00:16:13.462 --> 00:16:16.619 than 4 ounces of plain water and a 30-minute wait before food, 00:16:16.790 --> 00:16:21.170 drinks or other oral medicines. Foundayo permits food and uses a 30-day 00:16:21.212 --> 00:16:24.434 contraceptive precaution after initiation and each escalation. 00:16:24.711 --> 00:16:28.892 Verify the exact label. Separating tablet and injection times does not replace 00:16:29.021 --> 00:16:33.889 Zepbound’s precaution. The next escalation review includes the documented contraception plan. 00:16:34.166 --> 00:16:38.081 In another variation, Nora has type 2 diabetes controlled with a G 00:16:38.081 --> 00:16:42.806 L P 1 receptor agonist. She plans pregnancy and proposes stopping treatment 00:16:42.934 --> 00:16:46.945 until her first prenatal visit. Which plan best addresses this change? 00:16:47.329 --> 00:16:49.754 Pause here if you would like to consider your next step. 00:16:50.046 --> 00:16:54.782 The plan must address both medication discontinuation before conception and ongoing glucose 00:16:54.910 --> 00:17:00.616 management. Plan time to select and titrate pregnancy-appropriate treatment and establish monitoring. 00:17:00.903 --> 00:17:03.228 Include nutrition support and a named contact. 00:17:03.591 --> 00:17:10.247 Coordinate the transition before conception. The Endocrine Society/ESE guideline suggests discontinuation before 00:17:10.417 --> 00:17:16.667 conception. Evidence certainty is very low; individualize timing with active glycemic management. 00:17:16.923 --> 00:17:20.284 Send the regimen, glucose information and reproductive goal. 00:17:20.573 --> 00:17:25.287 Document alternative treatment, monitoring, prescriber and contact for changing readings. 00:17:25.607 --> 00:17:30.301 Unexpected pregnancy needs prompt exposure and maternal review; Zepbound labeling calls for 00:17:30.343 --> 00:17:35.191 discontinuation. Limited safety evidence does not predict an individual fetal outcome. 00:17:35.447 --> 00:17:38.412 Coordinate endocrinology, pregnancy care and nutrition. 00:17:38.690 --> 00:17:42.520 Assess lactation separately using current product and formulation information. 00:17:42.893 --> 00:17:47.629 Write the transition, monitoring plan, accepting clinician and review date, including what 00:17:47.672 --> 00:17:49.464 to do if pregnancy occurs sooner. 00:17:49.933 --> 00:17:53.773 In a separate variation, Nora starts Foundayo for obesity while using oral 00:17:53.816 --> 00:17:58.674 hormonal contraception. She assumes an oral medicine needs no contraceptive precaution. 00:17:58.994 --> 00:18:02.318 Which instruction matches the July 2026 label? 00:18:02.865 --> 00:18:06.470 Use the label’s 30 days after initiation and each escalation. 00:18:06.833 --> 00:18:11.078 Discuss a feasible non-oral or added-barrier method and record the dates. 00:18:11.483 --> 00:18:17.357 Injectable Wegovy for obesity. Specific reproductive teaching point: Discontinue at least two 00:18:17.443 --> 00:18:22.712 months before planned pregnancy. Coordinate preconception care and ongoing treatment needs. 00:18:23.075 --> 00:18:29.964 Zepbound. Specific reproductive teaching point: For oral hormonal contraception: non-oral method or 00:18:30.049 --> 00:18:33.996 added barrier for four weeks after initiation and each escalation. 00:18:34.359 --> 00:18:40.564 Foundayo. Specific reproductive teaching point: For oral hormonal contraception: non-oral method or 00:18:40.649 --> 00:18:44.468 added barrier for 30 days after initiation and each escalation. 00:18:44.830 --> 00:18:49.630 Discontinue when pregnancy is recognized. The July 2026 label does not recommend 00:18:49.843 --> 00:18:54.750 use in nursing women. Planned-pregnancy stopping intervals and temporary contraception precautions answer 00:18:54.920 --> 00:19:00.103 different questions. Diabetes requires ongoing glycemic care; lactation needs a separate label 00:19:00.188 --> 00:19:04.156 review. Teach-back: “Which method will you use, and which dates does the 00:19:04.199 --> 00:19:07.132 precaution cover?” Use the correct reproductive timing. 00:19:07.378 --> 00:19:12.264 Check product, formulation, indication and reproductive goal before assigning dates. 00:19:12.541 --> 00:19:14.226 Use the timeline to check the dates. 00:19:14.461 --> 00:19:18.514 In the diabetes variation, confirm who will arrange treatment and monitoring before 00:19:18.728 --> 00:19:25.356 discontinuation. Before the handoff. Record the exact product, formulation, indication, and reproductive 00:19:25.527 --> 00:19:29.708 goal. Specify product-dependent timing and contraceptive counseling. 00:19:30.050 --> 00:19:33.047 Plan ongoing glycemic treatment when diabetes is present. 00:19:33.356 --> 00:19:36.855 Name the next clinician, the review date, and the action if plans 00:19:36.983 --> 00:19:41.488 change. Before you go, bring the three cases back to one question: 00:19:41.786 --> 00:19:44.007 what will you do differently at the next visit? 00:19:44.265 --> 00:19:47.167 Complete the right test, match treatment to the outcome you want to 00:19:47.252 --> 00:19:51.557 improve, and keep nutrition, function and reproductive plans in the conversation. 00:19:51.894 --> 00:19:56.246 You’ll find the source references, transcript and clinical resources beside this episode. 00:19:56.673 --> 00:19:59.958 To record your answers and complete the learning activity, return to the 00:20:00.001 --> 00:20:02.593 activity page for the questions and brief evaluation. 00:20:02.968 --> 00:20:05.271 This has been HEART RESERVE Clinical Conversations. 00:20:05.527 --> 00:20:07.743 I’m Lisa Zahakos. Thank you for listening.