Case study 4 : Diabetes, polypharmacy and chronic kidney disease
Type 2 diabetes mellitus: Quality prescribing strategy - a guide for improvement
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.
