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.