Case study 3: Diabetes, SGLT-2is and managing adverse effects
Quality prescribing strategy for type 2 diabetes mellitus: a guide for improvement
Background (age, sex, occupation, baseline function)
- 52 years old
- Female
History of presentation/reason for review
- Annual diabetic review
Current medical history and relevant co-morbidities
- Type 2 diabetes mellitus – 3 years ago
- Established ASCVD
- Essential hypertension - 2 years ago
- Ischaemic heart disease – 2 years ago
- Coronary artery stenting of two vessel disease 2 years ago
Current medication and drug allergies (include OTC preparation and herbal remedies)
- Atorvastatin 40mg tablets – one tablet at night
- Clopidogrel 75mg tablets – one tablet daily
- Lisinopril 20mg tablets – one tablet daily
- Metformin 500mg tablets – one tablet twice daily
Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity
- Smokes 10 cigarettes per day
“What matters to me” (patient ideas, concerns and expectations of treatment)
- “I want to be on the right medicine for my heart”
Results e.g., biochemistry, other relevant investigations or monitoring
- Weight 92kg; height 1.7m; BMI 32.4 kg/m2
- Creatinine 55micromol/l; eGFR>60
- Urine albumin 3mg/ml, urine creatinine 9.1mmol/l, ACR 0.3mg/mmol
- HbA1c 51mmol/mol
- BP 126/78mmHg
Most recent relevant consultations
- Smoking cessation advice and referral made
- HbA1c above recommended target of 48 mmol/mol
- Would from commencing an SGLT-2 inhibitor – both from glycaemic and ASCVD point of view
- Empagliflozin 10mg once daily commenced
- Counselled on side effects
- Sick day guidance reiterated and personalised medication list updated via ManageMeds app/website.
- Four weeks after commencement presents with symptomatic genital thrush
- Clotrimazole ‘Combi pack’ prescribed
- Initial improvement in thrush, but after 2 weeks has recurred
- Fluconazole 150mg dose prescribed
- ‘Genital washing’ instructions given
- Option of more prolonged course of fluconazole, if thrush recurs – 150mg every 72 hours for 3 doses, then 150mg once weekly for 6 months
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
-
Appropriate treatment of cardiovascular disease - “I want to be on the right medicine for my heart”
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 all medication
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
- None are unnecessary
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
- HbA1c 51mmol/mol (above recommended target of 48 mmol/mol)
- Existing ASCVD – SGLT-2i* indicated– both from glycaemic and ASCVD point of view
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
- Counselled on risks of side-effects:
- the signs and symptoms of DKA, and advise to seek immediate medical advice if they develop any of these symptoms
- increased risk of genital infections
- avoid low carbohydrate diets
Sick Day guidance
- temporarily stop metformin, lisinopril and empagliflozin
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
- Smoking cessation advice and referral made
- Empagliflozin 10mg once daily commenced
- Note: 4 weeks after commencement presents with symptomatic genital thrush
- Clotrimazole ‘combi pack’ prescribed
- Initial improvement in thrush, but after 2 weeks has recurred
- Fluconazole 150mg dose prescribed
- ‘Genital washing’ instructions given
Key concepts in this case
- Established ASCVD indicates additional therapy of SGLT2i, independent of glycaemic control
- SGLT2i have known side effect profile
- Requirement to counsel patient accordingly
- Manage side-effects
- Use of simple instructions to minimise side-effects using “genital washing” leaflet (as developed by NHS Lothian). Leaflets for both male and female genital washing advice are available to download
- Reiterate sick day guidance and include SGLT-2i
Click on the table image to view a PDF version of the full 7 steps table.
