Download Health Care Plan Priority Therapeutic Plan Recommendations for

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Type 2 Diabetes Mellitus
Case Presentation
Wintana Teklehaimanot
Shantana Jones
4th year PharmD Candidates
Florida A&M College of Pharmacy
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Patient Presentation
CC:

“I would like to get my blood pressure and blood sugar checked”
HPI:

Lauren Johnson (LJ) is a 46 yo woman who comes to the pharmacy
for a regularly-scheduled wellness day (an open clinic day for
pharmacy-based screening services). She would like for the
pharmacist to check her blood sugar and blood pressure. She was
diagnosed with type 2 diabetes two years ago. She has been
controlling her disease with diet and exercise. She has lost 100
pounds over the past two years and states that she feels a lot
better. Ms. Johnson’s log book indicates that she has been
monitoring her blood glucose levels twice a day (before
breakfast and dinner) with a range of 150 to 200 mg/dL. Her
fasting levels average 170 mg/dL. She has been able to lose
weight by going to the gym 3 times a week and minimizing her
carbohydrate intake.
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History
PMH
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Type 2 DM X 2 years
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HTN X 10 years
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Breast CA 1996
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Depression X 7 years
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Osteoarthritis in both knees

Carpal tunnel syndrome (bilateral)
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History
SH

Married for 30 years, keeps children in her home during the day,
denies the use of tobacco and quit drinking alcohol about 10
years ago
FH

Maternal grandmother and fraternal grandfather had DM; father
has HTN; mother died at 63 from MI; daughter had asthma
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History
ROS

Denies nocturia, polyuria, polydipsia, nausea, constipation,
diarrhea, signs or symptoms of hypoglycemia, paresthesias, and
dyspnea
Allergies

Codeine – hives, headache

Penicillin – hives
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Medications

Effexor 25mg ½ tabs po BID
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Prinivil 10mg po QD
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Glucosamine/chondroitin 500mg po TID
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Chromium 10 mcg po TID
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EC ASA 81mg po QD
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B-100 Complex, 1capsule po BID
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Aleve 220mg tablets po Q 12 H PRN
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Objective
Physical Examination
Gen:

WDWN severely obese, white woman in NAD
VS
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BP 142/88, P 84, RR 18, T 38.6°C, Wt 111kg, Ht 5’5’’ (BMI= 40.6)
HEENT
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PERRLA, EOMI, R&L fundus exam without retinopathy
CV
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RRR, no m/r/g
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Objective
Lungs:

Clear to A&P
Abd:
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NT/ND
Genit/Rect
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Deferred
MS/Ext
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Carotids, femorals, popliteals, and right dorsalis pedis pulses 2+
throughout; left dorsalis pedis 1+; feet show thick calluses on MTPs
Neuro:

DTRs 2+ throughout, feet with normal sensation (5.07 monofilament)
and vibration
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Laboratory
Patient’s Lab Values
Normal Lab Values
Na 139 mEq/L
136-146 mEq/L
K 3.6 mEq/L
3.5-5.1 mEq/L
Cl 103 mEq/L
98-111 mEq/L
CO₂ 31mEq/L
32-45 mEq/L
BUN 15mg/dL
6-20 mg/dL
SCr 0.8 mg/dL
0.6-11 mg/dL
Gluc (random) 249 mg/dL
70-110 mg/dL
Ca 9.4 mg/dL
8.6-10 mg/dL
Phos 3.3 mg/dL
2.4-4.4 mg/dL
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Laboratory
Patient’s Lab Values
Normal Values
AST 15 IU/L
10-20 IU/L
ALT 18 IU/L
7-35 IU/L
Alk Phos 62 IU/L
32-92 IU/L
T. bili 0.4 mg/dL
0.3-1.2 mg/dL
A1c 8.5%
< 7%
Fasting lipid profile:
T. chol 163 mg/dL
< 200 mg/dL
LDL 96 mg/dL
< 70 mg/dL (CV Risk)
HDL 32 mg/dL
40-60 mg/dL
Trig 173mg/dL
< 150 mg/dL
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Urinary Analysis

2+ Protein, (+) microalbuminuria
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Assessment

The patient reports adherence to diet, exercise, and drug therapy
as prescribed. Her glycemic control has improved somewhat (A1c
previously was 10.1%) with lifestyle modification and weight
reduction, BP has remained consistent for the past year. She has
lost 45kg in the last 2 years. Her glycemic control and blood
pressure have not improved adequately despite her nutritional
and drug therapy.
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Assessment
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Uncontrolled diabetes
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Dyslipidemia (evelated TG, suboptimal HDL, Suboptimal
LDL)
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Microalbuminuria
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Uncontrolled hypertension
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At risk for Metabolic syndrome
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Plan
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Evaluate and assess current medication
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Initiate treatment for her DM 2
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Initiate treatment for her elevated LDL and triglyceride and
her low HDL levels
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Initiate treatment for her microalbuminuria and hypertension
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Follow up information
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Counseling tips
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Drug Therapy Assessment
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Drug Therapy Assessment
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Appropriate Drug Selection:
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Drug Regimen:
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Effexor could possibly be increasing her triglycerides, consider
Cymbalta 20mg BID initially then increase to 60mg once daily or
30mg BID
LJ is currently taking Effexor 25 mg 1/2tab BID, for depression,
Effexor should be dosed 75mg BID or TID with a max of 375mg/d
Prinivil is dosed 10mg once daily, the maintenance 20 to 40 mg once
daily
Therapeutic Duplication:

The patient is currently using Chromium to control her blood sugar. If
the patient start using anti-diabetic medication to control her blood
sugar there will be a duplication of therapy
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Drug Therapy Assessment
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Drug interaction:
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Effexor and Aleve or Aspirin concurrent use may increase risk of
bleeding
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Aspirin and Naproxen concurrent use may increase risk of
serious gastrointestinal adverse effects (ulceration, bleeding,
perforation)
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Pharmacist
Care Plan
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Pharmacist Care Plan
Health Care
Plan
Priority
Therapeutic
Plan
Recommend
ations for
Therapy
Monitoring
Parameters
Diabetes
1
Metformin
(Glucophage)
500mg BID
• Improvements
in fasting blood
glucose ad
HbA1c levels
• Self-monitoring
of blood
glucose
• Renal Function
• Hematologic
parameters:
baseline and
annually
• Vit B12 levels
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Pharmacist Care Plan
Health Care
Plan
Priority
Therapeutic
Plan
Recommendatio Monitoring
ns for Therapy
Parameters
Hypertension
2
Lisinopril (Prinivil)
20 mg once daily
• Blood pressure
• Hepatic and Renal
function
• Potassium levels
• Serum Creatinine
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Pharmacist Care Plan
Health Care
Plan
Priority
Therapeutic
Plan
Recommendati Monitoring
ons for Therapy Parameters
Depression
3
Cymbalta (Duloxetine)
20mg BID initially
then increase to 60mg
once daily or 30mg
BID
• Reduction or
improvement of
depression or
associated
symptoms
• Worsening of
depression,
suiciadality, or
unusual changes in
behavior
• Signs or symptoms
of serotonin
syndrome
• Blood pressure
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Pharmacist Care Plan
Health Care
Plan
Priority
Therapeutic
Plan
Recommendat Monitoring
ions for
Parameters
Therapy
Dyslipidemia
4
Lipitor
(Atorvastatin)
20 mg once daily
• Lipid panel
• Liver function
• Any signs of
myopathy
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Counseling tips

Calcium and Vitamin D supplementation
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Continue with regular exercise, at least 150min per week and
resistance training at least 2 times per week
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Encourage low fat (<7% of total calories), low carb (50%
whole grain, 14g/100g fiber) diet that maximizes weight loss,
limit protein intake to 0.8-1.0g/kg body weight/day for
patients with diabetes and early CKD
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Adhere to annual foot care, eye exams, vaccinations
(influenza, hepatitis B)
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Beware of symptoms of hyperglycemia and hypoglycemia
(carry glucose tablets with you at all times)
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References

AACE Comprehensive Diabetes Management Algorithm
2013. Endocrine Practice. American Association of Clinical
Endocrinologists. Vo. 19. 2013. ISSN: 1530 891X (Print); 19342403 (Online) Pg. 327-336

DiPiro, Joseph T., Robert L. Talbert, et al. Pharmacotherapy, A
Pathophysiologic Approach (Chapter 16: Heart Failure). 7th. 7.
New York: McGraw-Hill, 2008. 1205-1237. Print.

Micromedex® Healthcare Series.n.d. Thomson Healthcare,
Greenwood Village, CO. 24 Jan. 2013 [Internet}: Available at:
http://www.thomsonhc.com

Standards of Medical Care in Diabetes—2013. American
Diabetes Association. 2013. Diabetes Care. 2013 36:S11-S66;
doi:10.2337/dc13-S011
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QUESTIONS ??