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Managing Clinical Problems in Diabetes, Case Study #15: Pharmacotherapeutic Management

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

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Mr. VR was referred to the endocrinology department of a major hospital to ‘get his diabetes fixed up’ after he presented to the emergency department. Mr. VR is a 69-year-old man with type 2 diabetes of many years’ duration. He has high postprandial blood glucose levels in the morning — up to 288mg/dL from 126mg/dL (16 mmol/L from ~7 mmol/L) and before tea up to 180mg/dL (10 mmol/L)….

 
Current medications:
  • metformin 500 mg TDS
  • gliclazide 1 mg BD
  • Actos (pioglitazone) 30 mg mane
  • Verapamil: dose not specified
  • Aspirin dose not specified
  • Coversyl (perindopril) dose not specified
  • He has nocturia, which is disturbing his sleep.
  • His gliclazide was increased to the above dose to improve the problem of postprandial hyperglycemia and nocturia with no effect.

What do I do now?

General practitioner

Mr. VR has several issues. These include nocturia that could be related to Actos (pioglitazone), which causes fluid retention and hyperglycemia, or prostate problems. He has both fasting and postprandial hyperglycemia that has not improved despite increasing his OHA doses. I would like to know his HbA1c. I would check the basics to assess whether Mr. VR is eating appropriately and is suitably active.

The first consideration is to ensure that Mr. VR is taking all his medications appropriately. In a survey performed by Ultrafeedback, fewer than three in four patients said they always took medication as directed; 23% admitted they sometimes forgot to do so, and 4% said they generally did not take prescribed medications at all. There are many reasons for these findings such as cost, the number of tablets, knowledge about the medication, and age. People should be asked about their medication use in a non-judgmental manner. Assessing medication self-management is an important aspect of managing chronic illnesses such as diabetes.

Mr. VR needs a medication review that can be undertaken by his doctor, or a formal medication review could be undertaken by a pharmacist through the home medication review (HMR.) program to help determine his medication self-management practices and improve his understanding of — and compliance with — medication. Involving pharmacists in medication management can lead to reductions in HbA1c of ~ 1%.

Increasing his OHA doses is worthwhile because he is not on maximal doses of Diamicron (gliclazide). Reducing his metformin dose to 1 mg BD should be considered because compliance with TDS dosing is usually poor and the side effects of 2 mg TDS could be contributing to non-compliance.

Mr. VR’s nocturia needs to be assessed by taking a full history and relevant investigations, including a prostate check. Assuming that the nocturia is not related to prostate disease, fluid retention from Actos should be considered, as well as nocturnal hyperglycemia. With a fasting glucose of 126mg/dL (7 mmol/L) fluid retention is likely to be the cause of the nocturia. Controlling the glucose levels overall is a good first line strategy. If that does not improve Mr. VR’s nocturia, consideration should be given to stopping Actos, especially if he has significant fluid retention and peripheral oedema.

The strength of primary care is the ability to have timely reviews of patients especially when the diagnosis is not clear.

Diabetes educator

The GP has addressed the important considerations. I would also assess Mr. VR’s blood glucose testing technique to determine how long after food he waits before testing his blood glucose. If he is testing soon after a meal, he may be recording post-absorptive glucose levels, which are likely to be higher than postprandial levels measured 2 hours after food. He may need a diet and exercise review.

The possibility of silent urinary tract infection needs to be considered and a microurine and culture is indicated. Nocturia disrupts sleep and reduces quality of life. 

Pharmacotherapeutic Management

Key points
  • Medicines should be used in a quality use of medicines framework.
  • The medicine regimen should be reviewed regularly, for example as part of routine complication screening, pre- and postoperatively and when stable conditions change.
  • Polypharmacy is often necessary to manage the multiple underlying metabolic abnormalities associated with diabetes and its complications and comorbidities.
  • Polypharmacy complicates self-management for the person with diabetes and adds to the cost of managing diabetes.
  • Concordance with medicines is a complex self-care task that has physical, cognitive, and mental components. Medicines knowledge and social factors also play a role.
  • Diet and exercise continue to be essential, even when medicines are needed.

The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The specific health professionals who provide comments about each case depend on the specific clinical issue; and (3) stimulate thought and discussion. 

The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.

Next Week: Case Discussion

For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetesalt

Copyright © 2008 by Blackwell Publishing Ltd, UK

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath