B.pharma 4th year patients case study format

Patient details

Name: MR. *****	Age: 50 years	Sex: M
Date of admission: 2019/03/28	Date of discharge: 2019/03/30	Hospital No: 880816

Diagnosis/Impression:

Uncontrolled diabetes mellitus

Type 2 diabetes mellitus consists of an array of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion.

Clinical History and Examination

• K/C/O HTN under tazloc 40 mg (no docments)
• DM (not under medication)

Complain of:

1. Generalized weakness for 1 day
2. Alcohol drinking 2 days back following which he had multiple episodes of vomiting which subsided spontaneously.
3. Bowel, bladder normal

 

On examination:

GC: fair

PILCCOD: NIL

Vitals:

• Pulse: 80/min, regular
• BP: 120/80 mmHg
• RR: 18/min

Systemic Examination:

• P/A: Soft, non-distended
• Diffuse deep tenderness present
• Chest: Bilateral equal air entry, normal resicular breath sound, no added sound
• CVS: S1S2M0

Investigation:

Date: 2019/03/28

Parameter	Observed value	Units	Reference range
Glucose, Random	325	mg/dl	60.0-150.0
Creatinine	1. 1	Mg%	0.4-1.4
UREA	45	Mg/dl	10-45
AST(SGOT)	18	IU/L	5-40
ALT(SGPT)	28	IU/L	5-40
Sodium	132	mEq/L	135-148
Potassim	4.4	mEq/L	3.5-5.3
TC	9600	Mm3	4000-11000
Neutrophils	60	%	45-75
Leukocytes	32	%	20-45
Platelets	269000	%	150-450
Hemoglobin	15.4	g/dl	13-17

1.  HBA1C=11.2 (ref=<6)
   · URINE RME=3+
   · ALB NOT DETECTED
2. URINE RME:
   - PUS CELLS=2-4
   - EPI CELLS=1-3
   · KETONE=NEGATIVE
   · ECG=RBBB
   · ABG:PH=.44
   · PCO2=29.7
   · PO2=60
   · HCO3=21.9
   · ANION GAP=18.7

2019/02/29

Parameters	Result	Units	Reference range
ALT	28	IU	5-40
AST	18	%	5-40
FBS	149	Mg/dl	60-100
Total Cholesterol	172	Mg/dl	Desirable: <200; 200-239:borderline; >240:high
HDL	32	Mg/dl	M>60;F>75 desirable Acceptable: 35-45; low: <35
LDL	103	Mg/dl	<100 optimal; 130-159; above
TAG	189	Mg/dl	<130:desirable; 139-159: boarderline
NON HDL	140	Mg/dl	<130 desirable; 139-159:boarderline
SODIUM	137	MEq/l	135-145
POTASSIUM	4.2	Meq/l	3.5-5.3

Cardiac Ratio: 5.3

Fundoscopy: No Diabetic Retinopathy

Echo: Concentric LVH; Diastolic Dysfunction; Mild TR

Treatment given at the hospital:

1^st day

•  Inj pantoprazole 40 mg OD
•  Inj ondem 4 mg IV SOS
• Tab Tacloc 40 mg PO OD

 

2^nd day till discharge:

Medication prescribed were:

•  Inj pantoprazole 40 mg OD
•  Tab tazloc 40 mg PO OD
• Tab metformin 500 mg SR PO BD
• Tab atorvastatin 10 mg PO HS
•  Tab aspirin 75 mg PO HS
•  Inj Insman(25:75)= 24 U s/c before lunch, 12 U s/c before dinner

Course of illness in the hospital:

50 years’ male presented to DH with generalized body weakness and multiple episode of vomiting following binge alcohol drinking 2 days’ bac. He is a K/C/O HTN under Tazloc 40 mg (no document) and DM (not under medication). Relevant investigations were sent which showed high blood glucose HBA1C of 11.2%. he was managed with the above medications in the line of uncontrolled diabetes mellitus. The blood glucose level lowered and he is stable at the time of discharge.

Advice on discharge:

•      Inj. Insuman(25:75) 24 units S/C before lunch and 12 unit SC before dinner to continue.

•      Tab metformin SR 500 mg PO BD to continue

•      Tab Atorvastatin 10 mg PO HS to continue

Tab aspirin 5 mg PO OD to continue

Follow up: After 2 weeks with FBS and PPBS report/SOS

Pharmacology of Drugs used^[1]:

1.      Metformin SR:

It is an antidiabetic drug under class; biguanides.

MOA: Decreases hepatic glucose production; decreases GI glucose absorption; increases target cell insulin sensitivity.

SR means sustained release tablets.

·         Bioavailability: 50-60%

·         Peak plasma time: Regular-release: 2-3 hr

                               Extended-release: 4-8 hr

·         Half-Life: 4-9 hr.

 

2.      Mixtard Insulin(30:70):

Insuman 25/75 Suspension for Injection 40IU/ml is a combination of two insulin preparations: Insulin Isophane / NPH and Human Insulin / Soluble Insulin. Insulin Isophane / NPH has a prolonged duration of action, while human insulin / soluble insulin has a fast onset of action. Together, they ensure rapid and consistent sugar control by facilitating reuptake of sugar in muscle and fat cells and suppressing the production of sugar in the liver.

MOA: Insulin and its analogues lower blood glucose by stimulating peripheral glucose uptake, especially by skeletal muscle and fat, and by inhibiting hepatic glucose production; insulin inhibits lipolysis and proteolysis and enhances protein synthesis; targets include skeletal muscle, liver, and adipose tissue.

3.      Pantoprazole:

It is a proton pump inhibitor.

MOA: It binds to H+/K+-exchanging ATPase (proton pump) in gastric parietal cells, resulting in blockage of acid secretion.

·         Bioavailability: 77% (PO; neither food nor antacid alters bioavailability)

·         Peak plasma time: 2.8 hr (PO)

·         Half-life: 1 hr; increased to 3.5-10 hr with CYP2C19 deficiency.

 

4.      Aspirin:

MOA: Inhibits synthesis of prostaglandin by cyclooxygenase; inhibits platelet aggregation; has antipyretic and analgesic activity.

·         Bioavailability: 80-100%

·         Onset: PO, 5-30 min; PR, 1-2 hr

·         Duration: PO, 4-6 hr; PR, >7 hr

·         Peak plasma time: PO, 0.25-3 hr

·         Half-life: Low dose, 2-3 hr; higher dose, 15-30 hr

 

5.      Atorvastatin:

MOA: HMG-CoA reductase inhibitor; inhibits rate-limiting step in cholesterol biosynthesis by competitively inhibiting HMG-CoA reductase

·         Bioavailability: 14% (parent drug)

·         Onset: 3-5 days

·         Duration: 48-72 hr

·         Peak serum time: 1-2 hr

·         Half-life: 14 hr

 

6.      Telmisartan

MOA: Angiotensin II receptor blocker; inhibits vasoconstrictor and aldosterone-secreting effects of angiotensin II

·         Onset: 1-2 hr

·         Duration: <24 hr

·         Peak plasma time: 0.5-1 hr

·         Half-life: 24 hr

 

7.      Ondansetron

Mechanism not fully characterized; selective 5-HT3 receptor antagonist; binds to 5-HT3 receptors both in periphery and in CNS, with primary effects in GI tract. Has no effect on dopamine receptors and therefore does not cause extrapyramidal symptoms

-          Bioavailabilty: 56-71% (PO); food increases extent of absorption (17%)

-          Peak plasma time: IV, end of infusion; IM, 30 min; PO, 2 hr (tablet) or 1 hr (soluble film)

-          Half life: 2-7 hr (children <15 years); 3-7 hr (adults); patients with mild to moderate hepatic impairment, 12 hr; patients with severe hepatic impairment (Child-Pugh class C), 20 hr

 

 

Guidelines:

Principles of The Aace/Ace Comprehensive Type 2 Diabetes Management Algorithm^[2]

1. Lifestyle modification underlies all therapy (e.g., weight control, physical activity, sleep, etc.)

2. Avoid hypoglycemia

3. Avoid weight gain

4. Individualize all glycemic targets (A1C, FPG, PPG) 5. Optimal A1C is ≤6.5%, or as close to normal as is safe and achievable

 6. Therapy choices are patient centric based on A1C at presentation and shared decision-making

 7. Choice of therapy reflects ASCVD, CHF, and renal status

8. Comorbidities must be managed for comprehensive care

 9. Get to goal as soon as possible—adjust at ≤3 months until at goal

10. Choice of therapy includes ease of use and affordability

 11. CGM is highly recommended, as available, to assist patients in reaching goals safely

Pharmacist’s view and interference:

ü  The use of metformin and Insulin are under the international guideline for the management of DM type 2 and are used to control blood sugar level.

ü  Telmisatran and atorvastatin is used to reduce the risk of cardiovascular disease since the patients is hypertensive and high lipid profile.

ü  The use of pantoprazole may be used to tread gastroesophageal reflux.

ü  Low dose aspirin is used for the prophylaxis of MI

ü  Patient is also to be counseled about the timely monitoring of blood glucose, blood pressure and cholesterol level.

ü  Patient should be counseled about prevention of any cuts and wound especially in feet (foot hygiene).

ü  Patient is to be counseling about regular checkup of eyes, kidney function and heart.

ü  Patient is also to be counseled about carrying sugary candy along with him/her so to consume in case of any hypoglycemic attack.

ü  The pharmaceutical care plan for the patients is to control the blood sugar along with blood pressure through the both pharmacological and non-pharmacological method, by increasing compliance and awareness about the disease.

Conclusion:

The treatment followed in the case, all prescribed drugs are rational. The case treatment is done following the international treatment guideline.

References

1.         Medscape. DRUGS & DISEASES  [Available from: https://reference.medscape.com/.

2.         Quattrocchi E, Goldberg T, Marzella N. Management of type 2 diabetes: consensus of diabetes organizations. Drugs in Context. 2020;9:212607.