Case study 2: Polypharmacy and symptomatic diabetes
Type 2 diabetes prescribing
Background (age, sex, occupation, baseline function)
- 85 year old
- Male
History of presentation/reason for review
- Rising HbA1c and reporting osmotic symptoms
Current medical history and relevant co-morbidities
- Type 2 diabetes mellitus – 18 years ago
- Ischaemic heart disease – 11 years ago
- Hypertension – 17 years ago
- Bilateral diabetic retinopathy – 6 years ago
- Chronic Kidney Disease Stage 3–5 years ago
- Autoimmune gastritis – 5 years ago
- Macrocytic anaemia – 5 years ago
- Pernicious anaemia – 5 years ago
- Albuminurea – 2 years ago
Current medication and drug allergies (include OTC preparation and herbal remedies)
- Aspirin dispersible 75mg tablets - one tablet daily
- Bisoprolol 2.5mg tablets - one tablet daily
- Ferrous fumarate 322mg tablets - one tablet twice daily
- Folic acid 5mg tablets - one tablet daily
- Gliclazide 160mg tablets - two tablets twice daily
- GlucoRx Nexus test strips - use as directed
- Glyceryl trinitrate 400mcg sublingual spray - use when required
- Hydroxocobalamin 1mg IM injection - once every 3 months
- Linagliptin 5mg daily - one tablet daily
- Losartan 50mg daily - one tablet daily
- Metformin 500mg tablets- two tablets twice daily
- Omeprazole 20mg capsules - one capsule daily
- Simvastatin 40mg tablets - one tablet night
Drug Allergies:
- SGLT-2i previously not tolerated due to recurrent balanitis
Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity
- Rockwood score 4 (vulnerable)
- Lives alone, daughter visits daily
- Wife died in 2021 (dementia) - he was her main carer
- Continues to drive (short distances)
- Eating more than normal and has put on weight
- Attends diabetic retinopathy screening
- Attends podiatrist regularly
“What matters to me” (patient ideas, concerns and expectations of treatment)
- Wishes he didn’t need to take so many medications but organises and fills a compliance aid himself
- Often forgets to take his dose of statin at night
- Struggles to check blood glucose so doesn’t undertake home blood glucose monitoring, however test strips on repeat and issued regularly
- Tired and not going out much – feels “a bit lost since his wife died”
Results e.g., biochemistry, other relevant investigations or monitoring
- Creatinine 127micromol/L and eGFR = 47 ml/min
- Weight 117kg; height 182cm; BMI 35.32
- Calculated creatinine clearance 49ml/min (IBW 77kg)
- Urine albumin 18mg/ml, urine creatinine 2.5 mmol/l, ACR 7.2mg/mmol
- No urinary protein detected
- Recent LFTs normal, FBC stable (Hb 123 g/l), folate > 20microg/l
- Last 3 blood pressures 130/63mmHg, 118/62mmHg, 128/62mmHg
- Serum cholesterol 3.9mmol/l, ratio 3.5, triglycerides 3.0mmol/l
- Hba1c 97mmol/mol (3 months previously was 75mmol/mol)
Most recent relevant consultations
- HbA1c was 75mmol/mol 3 months ago and gliclazide was increased. New blood glucose monitor and test strips were issued.
- Recent leg wound/ulcer - dressed and treated by practice nurse
7 Steps: Person specific issues to address for case study 2
1. Aims: What matters to the individual about their condition(s)?
Review diagnoses and consider:
- Therapeutic objectives of drug therapy
- Management of existing health problems
- Prevention of future health issues, including lifestyle advice
Person specific actions
- Simplify and reduce medication burden
- Minimise symptoms and improve quality of life, e.g. reduce isolation, and improve mood as feeling “a bit lost”
- Reduce risk of adverse effects from drugs
2. Need: Identify essential drug therapy
Identify essential drugs (not to be stopped without specialist advice*)
- Drugs that have essential replacement functions
- Drugs to prevent rapid symptomatic decline
* with advice from healthcare professional with specialist interest
Person specific actions
- Although not considered essential, there is a valid indication for antidiabetic medication: diabetes symptom control
3. Does the patient take unnecessary drug therapy?
Identify and review the continued need for drugs
- what is medication for?
- with temporary indications
- with higher than usual maintenance doses
- with limited benefit/evidence for use
- with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)
Person specific actions
- Folic acid 5mg can be stopped as no longer deficient in folate
4. Effectiveness: Are therapeutic objectives being achieved?
Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives
- to achieve symptom control
- to achieve biochemical/clinical targets
- to prevent disease progression/exacerbation
- is there a more appropriate medication to achieve goals?
Person specific actions
- Diabetes poorly controlled despite 3 antidiabetics. Takes linagliptin, which is less effective than other options which also have positive cardiovascular outcomes
- Secondary CVD prevention: likely to derive macrovascular benefit from tight glycaemic control; is on statin and BP within target range
5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?
Identify individual safety risks by checking for
- appropriate individual targets
- drug-disease interactions
- drug-drug interactions (see ADR table)
- monitoring mechanisms for high-risk drugs
- risk of accidental overdosing
Identify adverse drug effects by checking for
- specific symptoms/laboratory markers
- cumulative adverse drug effects (see ADR table)
- drugs used to treat side effects caused by other drugs
Medication Sick Day guidance
Person specific actions
- Risk of hypoglycaemia due to renal impairment and on sulfonylurea – reduce and stop gliclazide
- Risk of acute kidney injury (losartan, metformin and CKD) especially if acutely unwell. Sick day guidance – check awareness
6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?
Identify unnecessarily costly drug therapy by
- considering more cost-effective alternatives, safety, convenience -
Consider the environmental impact of
- Inhaler use
- Single use plastics -
- Medicines waste
- Water pollution
Person specific actions
- None - prescribing in keeping with current formulary recommendations
- Patient advised to dispose of medicines through community pharmacy
- Advised patient to only order what is needed, do not stockpile medicines
7. Patient centeredness: Is the patient willing and able to take drug therapy as intended?
Does the person understand the outcomes of the review?
- Consider teach-back
Ensure drug therapy changes are tailored to individual’s preferences. Consider
- is the medication in a form they can take?
- is the dosing schedule convenient?
- what assistance is needed?
- are they able to take medicines as intended?
Agree and communicate plan
- discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
- include lifestyle and holistic management goals
- inform relevant health and social care providers of changes in treatments across the transitions of care
Person specific actions
- Discuss commencing once weekly injectable therapy with GLP-1RA and stopping linagliptin and also reducing and stopping gliclazide. Daughter happy to help with this as patient would prefer to inject subcutaneously into upper arm. Oral formulation available if preferred.
- Secondary CVD prevention – discussion around importance of weight reduction along with good control of BP, HbA1c and cholesterol. Change to atorvastatin in the morning. Provide support for lifestyle change where appropriate e.g., referral to Weight Management Service.
- Check patient’s understanding of how to best monitor glycaemic control through HbA1c testing and address that there is no need to routinely undertake SBGM. Remove test strips from repeats.
- Encourage attendance at local befriending groups, Men’s Shed, etc to reduce social isolation since his wife died.
Key concepts in this case
- Lifestyle management
- Polypharmacy, not limited to treatment of diabetes
- Symptomatic control required
Click on the table image to view a PDF version of the full 7 steps table.
