Case study

A Patient With Type 2 Diabetes

by
Saman shahjehan
06331513014
 Case presentation
B.L. is a 58-year-old white woman who has been referred to the pharmacist clinician for
pharmacotherapy assessment and diabetes management.
C=condition of a patient
• medical conditions
Her multiple medical conditions include type 2 diabetes diagnosed in 1995, hypertension,
hyperlipidemia, asthma, coronary artery disease, persistent peripheral edema, and
longstanding musculoskeletal pain secondary to a motor vehicle accident.
• medical history
Her medical history includes atrial fibrillation with cardioversion, anemia, knee replacement,
and multiple emergency room (ER) admissions for asthma.
• Current treatment
B.L.’s diabetes is currently being treated with a premixed preparation of 75% insulin lispro
protamine suspension with 25% insulin lispro preparation (Humalog 75/25), 33 units before
breakfast and 23 units before supper. She says she occasionally “takes a little more” insulin
when she notes high blood glucose readings, but she has not been instructed on the use of
an insulin adjustment algorithm.
• routine medications
• Her other routine medications include the fluticasone metered dose
inhaler (Flovent MDI), two puffs twice a day; salmeterol MDI (Serevent
MDI), two puffs twice a day; naproxen (Naprosyn), 375 mg twice a day;
enteric-coated aspirin, 325 mg daily; rosiglitazone (Avandia), 4 mg daily;
furosemide (Lasix), 80 mg every morning; diltiazem (Cardizem CD), 180 mg
daily (per cardiologist consult); lanoxin (Digoxin), 0.25 mg daily (per
cardiologist consult); potassium chloride, 20 mEq daily; and fluvastatin
(Lescol), 20 mg at bedtime.
• Medications she has been prescribed to take “as needed” include
sublingual nitroglycerin for chest pain (has not been needed in the past
month); furosemide, additional 40 mg later in the day if needed for
swelling (on most days the additional dose is needed); and albuterol MDI
(Proventil, Ventolin), two to four puffs every 4–6 hours for shortness of
breath. She denies use of nicotine, alcohol, or recreational drugs; has no
known drug allergies; and is up to date on her immunizations.
• chief complaint
• B.L.’s chief complaint now is increasing exacerbations of asthma and the
need for prednisone tapers. She reports that during her last round of
prednisone therapy, her blood glucose readings increased to the range of
300–400 mg/dl despite large decreases in her carbohydrate intake.
• She reports that she increases the frequency of her fluticasone MDI,
salmeterol MDI, and albuterol MDI to four to five times/day when she
has a flare-up. However, her husband has been out of work for more
than a year, and their only source of income is her Social Security check.
Therefore, she has been unable to purchase the fluticasone or salmeterol
and so has only been taking prednisone and albuterol for recent acute
asthma exacerbations.
• The memory printout from her blood glucose meter for the past 30
days shows a total of 53 tests with a mean blood glucose of 241
mg/dl . With a premeal glucose target set at 70–140 mg/dl, there
were no readings below target, 8% within target, and 91% above
target. By comparison, her results from the same month 1 year ago
averaged 112 mg/dl, with a high of 146 mg/dl and a low of 78 mg/dl.
Physical Exam
• B.L. is well-appearing but obese and is in no acute distress. A limited
physical exam reveals:
• Weight: 302 lb; height 5′1″
• Blood pressure: 130/78 mmHg using a large adult cuff
• Pulse 88 bpm; respirations 22 per minute
• Lungs: clear to auscultation bilaterally without wheezing, rales, or rhonchi
• B.L. reports that on the days her feet swell the most, she is active and in
an upright position throughout the day. Swelling worsens throughout the
day, but by the next morning they are “skinny again.” She states that she
makes the decision to take an extra furosemide tablet if her swelling is
excessive and painful around lunch time; taking the diuretic later in the
day prevents her from sleeping because of nocturnal urination.
• Lab Results
• Hemoglobin A1c (A1C) measured 6 months ago: 7.0% (normal range: <5.9%; target: <7%)
• Creatinine: 0.7 mg/dl (normal range: 0.7–1.4 mg/dl)
• Blood urea nitrogen: 16 mg/dl (normal range: 7–21 mg/dl)
• Sodium: 140 mEq/l (normal range: 135–145 mEq/l)
• Potassium: 3.4 mg/dl (normal range: 3.5–5.3 mg/dl)
• Calcium: 8.2 mg/dl (normal range: 8.3–10.2 mg/dl)
• Lipid panel
• • Total cholesterol: 211 mg/dl (normal range <200 mg/dl)
• • HDL cholesterol: 52 mg/dl (normal range: 35–86 mg/dl; target: >55 mg/dl,
female)
• • LDL cholesterol (calculated): 128 mg/dl (normal range: <130 mg/dl; target:
<100 mg/dl) Initial LDL was 164 mg/dl.
• • Triglycerides: 154 mg/dl (normal range: <150 mg/dl; target: <150 mg/dl)
• Liver function panel: within normal limits
• Urinary albumin: <30 μg/mg (normal range: <30 μg/mg)
O=outcomes desired for a condition
• 1. Mortality outcomes
Avoid respiratory, cardiovascular, thromboembolic, or diabetes-related premature
death.
2 Morbidity outcomes
• Disease-related: Reduce morbidity resulting from uncontrolled blood glucose, blood
pressure, dyslipidemia, and cardiovascular disease.
• Retard the progression of disease.
• Prevent, recognize, and treat early any complications of chronic conditions, such as
neuropathy (autonomic or peripheral), eye disease heart failure, myocardial
infarction), nephropathy (e.g., proteinuria, nephrosclerosis), and lower-leg
amputation.
• Prevent chronic symptoms of asthma (e.g., coughing or breathlessness at night, in the
early morning, or after exertion).
• Retain recognition of hypoglycemia symptoms.
• Maintain near-normal lung function.
Maintain normal activity levels (including exercise and other physical activity).
• Drug-related: Prevent, minimize, or manage drug-related morbidity.
• Monitor for side effects or toxicity.
• Monitor for drug-drug, drug-disease, and drug-food interactions.
3. Behavioral outcomes
• Develop a consistent support system.
• Adhere to a medication regimen.
• Get routine and timely medical examinations and laboratory tests.
• Avoid stimulants or over-the-counter products that may affect blood glucose, blood pressure,
asthma, or circulation, such as alcohol,
• caffeine, nicotine, and decongestants.
Pharmacoeconomic outcomes
• Keep drug and treatment costs within patient resources.
• Make cost-effective and efficient use of health care resources.
• 5. Quality-of-life outcomes
• Match, or only minimally change, patient lifestyle and activities with disease treatment.
• Aim for no missed days or interference with work, school, or daily activities because of disease
symptoms.
• Work to ensure patient satisfaction with the pharmaceutical care and health care team.
R=Regimens to achieve desired outcome
• Asthma
• Change fluticasone and salmeterol prescriptions to a single combination
product.
• Limit use of albuterol inhaler (short-acting -agonist) to rescue only.
• Consider addition of leukotriene inhibitor if symptoms are not controlled
by consistent use of inhaled corticosteroid (medium to high dose)
• and inhaled long-acting -agonist.
• Begin use of peak flow meter every morning upon arising.
• Develop and implement an asthma action plan.
• Remove or reduce exposure to environmental triggers.
• Diabetes
• Change insulin to a basal-based regimen using bedtime glargine and
premeal lispro to allow initiation and optimal use of insulin adjustment
• algorithms.
• Compensatory algorithm (insulin supplement, or “sliding scale”):
adjustments to compensate for unexpected, transient elevations of
• blood glucose such as from asthma exacerbation or prednisone therapy
• Prospective algorithm: adjustments to match premeal rapid-acting insulin
with anticipated carbohydrate ingestion at meals
• Dyslipidemia
• Change fluvastatin to atorvastatin.
• Persistent lower-extremity edema
• Elevate extremities for 20–30 minutes, two to three times during the day.
• Wear support stockings on days when B.L. is anticipating being on her feet
most of the day.
• Limit salt intake.
• Minimize use of nonsteroidal antiinflamatory drugs (NSAIDs) (see below).
• Hypokalemia
• Increase potassium chloride supplement temporarily; reassess
potassium level in 7–10 days. Titrate potassium dosage with
decreasing use of
• albuterol, furosemide, and prednisone to attain and maintain
potassium level of 3.5–5.0 mEq/l.
• Hypertension
• No changes at this time. Monitor and consider addition or change to
ACE inhibitor if additional antihypertensive effects are needed,
E=Evaluation of ADRS and Toxicity
• The last step is to develop a plan to evaluate the patient’s progress in
attaining desired outcomes, therapeutic endpoints, and behavior
changes; to assess effectiveness of pharmacotherapy; and to identify
side effects, drug interactions, or toxicity issues that need to be
addressed.
Monitoring: Effectiveness
Fluticasone/salmeterol combination inhaler

• Wheezing, shortness of breath

• Breath sounds
• Pulmonary function tests

• Monitoring: Toxicity/Adverse Reactions

• Parameters
• Headaches (12–13%)
• Pharyngitis; signs/symptoms of upper
• respiratory infection, sinusitis; oral candidiasis
• Conjunctivitis, eye redness, keratitis
• Monitoring: Effectiveness
• Glargine and lispro
• Blood glucose
• Hypoglycemic symptoms
• Hyperglycemic symptoms

• Monitoring: Toxicity/Adverse Reactions

Moderate or severe hypoglycemia,
requiring assistance
Injection site reactions: itching,
swelling, redness, lipodystrophy
Serum potassium