Background (age, sex, occupation, baseline function)

  • 59 year old male, works in family business
  • Lives with wife who does all the cooking

History of presentation/reason for review

  • Annual diabetes review

Current medical history and relevant co-morbidities

  • Type 2 diabetes mellitus – 10 years ago
  • CKD stage 3B – 1 years ago
  • Microalbuminuria – 4 years ago

Current medication and drug allergies (include OTC preparation and herbal remedies)

  • Atorvastatin 20mg tablets – one tablet daily
  • Gliclazide 80mg tablets – one tablet daily
  • Metformin 500mg tablets – one tablet twice daily
  • Ramipril 10mg capsules – one capsule daily

Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity

  • Non-smoker
  • Minimal alcohol
  • Diet can be improved
  • Plays golf three times weekly

“What matters to me” (patient ideas, concerns and expectations of treatment)

  • Concerned with reduced kidney function and diabetes control

Results e.g., biochemistry, other relevant investigations or monitoring

  • Weight 95kg, BMI 32
  • Blood pressure 136/84mmHg
  • eGFR 41ml/min
  • ACR 10mg/mmol
  • LFTs normal
  • Serum cholesterol 3.6mmol/l, Triglycerides 1.9 mmol/l
  • HbA1c 72mmol/mol
  • Foot screen- low risk
  • Retinal screen- mild retinopathy 

Most recent relevant consultations

  • Had U&Es checked 6 months previously - eGFR stable

7 Steps: Person specific issues to address for case study 4

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

  • Patient is concerned about his kidney condition and diabetes control.
  • Treatment objectives:
    • Stabilise CKD
    • Improve diabetes control
    • Improve blood pressure

 

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 considered 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

  • To achieve symptom control
    • CKD management: initiate SGLT-2i* to delay the progression of CKD.
  • BP control: BP slightly above target.
    • Already on ramipril 10mg daily.
    • Check BP after initiation of SGLT-2i.
  • HbA1c is above target and BMI is 32.
    • Check adherence.
    • Add in 3rd line hypoglycaemic agent (GLP-1RA). NB: SGLT-2i don’t exert their glucose-lowering effects in eGFR<45ml/min

 

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

  • SGLT-2i:
    • DKA symptoms*; check awareness
    • Raise awareness of thrush/UTI
  • GLP-1RA: raise awareness of GI ADRs and symptoms of pancreatitis
  • to monitor blood glucose and if below <4.0mmol/l, to stop gliclazide.

Sick Day guidance

  • risk of acute kidney injury (ramipril, metformin and CKD)

 

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

  • Delay progression of CKD:
    • Discuss that the addition of an SGLT-2i* will delay CKD progression and may have beneficial effect on BP control.
    • eGFR to be monitored at least 6 monthly.
    • Follow up patient 1-2 weeks post SGLT-2i initiation to check adherence, ADRs and BP.
  • BP control:
    • Discuss if BP still above target after initiation of SGLT-2i, then additional antihypertensive treatment will be added.
  • Diabetes management:
    • Once patient is stabilised on the SGLT-2i (1-2 weeks post initiation), initiate GLP-1RA-
    • Check patient understands how to inject GLP-1RA pen correctly and dosing frequency.
    • Follow up patient post initiation at week 1 months 3 and 6. And then every 3-6 months thereafter.
  • Non medication intervention: refer patient to a dietician. With patient’s permission, wife is to attend also.

 

Key concepts in this case

  • Prescribing for people with co-morbidities: CKD
    • management of CKD in type 2 diabetes 
    • tight blood pressure control
    • tight glycaemic control

 

Click on the table image to view a PDF version of the full 7 steps table.