Case study 2: Polypharmacy and symptomatic diabetes

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.