1. NURS 785: Pharmacotheraputics for Nurse Prescribing Assignment 3: Case Presentation Student ID: 5474635 Auckland University September 2014

2. Clinical reasoning framework Source: Levett- Jones et al, 2010

3. Mr Green, 75yrs old Type II DM TIA 16 years ago Atrial Fibrillation Dilated cardiomyopathy Hypertension Hyperlipidemia CKD Medications: Metformin 1g, BD Dabigatran 110mg BD Metroprolol 142.5mg OD Digoxin 62.5ug OD Accupril 2.5mg OD Frusemide 40mg OD Simvastatin 40mg OD Came into clinic for review of blood glucose control

4. Mr Green, 75 years old Gathering information Ejection fraction normal (Sanderson, 2007) No dyspnoea No postural hypotension No dizziness No chest pain or palpitations Chest clear No oedema HR 60 bpm, irreg BP 120/70 Weight 79kgs BMI 24.9

5. Mr Green, 75 years old Gathering information Hba1c 80 mmol/mol, previously 97 C-peptide – 1740 pmol/L eGFR 29 mls/min/1.73m 2, previously 31, 44 Creatinine 183 μmol/L Normal ACR - 1.5 mg/mmol (NZGG, 2012) Normal electrolytes Normal CBC, TSH, LFTs, lipids. No self blood glucose monitoring No allergies known Not taking any OTC meds

6. Mr Green, 75 years old Gathering information Cognitive decline History of poor compliance with oral medication and SBGM Minimal alcohol intake Non smoker Says he is feeling “wonderful” No symptoms of hyperglycemia Dietary assessment reveals appropriate diet for diabetes management Exercises > 30 mins/day

7. Mr Green, 75 years old Processing the information Stable cardiac symptoms Renal decline over the last year Creatinine clearance 34.5 mls/min (BPAC, 2009; Cockcroft & Gault, 1976) Hba1c > 50-55mmol/mol (NZGG, 2012) No self monitoring of BG levels Good current compliance with prescribed medications Mr Green’s wife plays significant role in maintaining Mr Green’s health

8. Mr Green, 75 years old Identifying the issues Marked insulin resistance, inadequate BG control (Canterbury Health Laboratories, 2013; NZGG, 2012) Poor renal function: ▫Metformin contraindicated (Medsafe, 2011; NZ Formulary, 2014a; Waitemata DHB, 2013) ▫Dabigatran used with caution (BPAC, 2013b; Medsafe, 2014; NZ Formulary, 2014b; CHADS2 score = 6 (requires anti-coagulation treatment) (BPAC, 2011) Memory/compliance/health literacy effecting self-management of diabetes

9. Mr Green, 75 years old Setting goals and taking action Goals Avoid drug toxicity due to poor renal function Glycemic control ▫Hba1c <65mmol or ▫“all values under 10” ▫fasting glucose no less than 6mmol ▫ no hypoglycaemia (< 4mmols) (BPAC, 2013a; Inzucchi et al., 2012; Skyler et al., 2009) Maintain no cardiac symptoms Improve self-management of diabetes

10. Mr Green, 75 years old Setting goals and taking action Treatment alternatives Stop frusemide, continue metformin if eGFR > 30ml/min (NZ formulary, 2014) ▫Or Stop metformin, start sulfonylurea or insulin (NZGG, 2012) Stop dabigatran, start warfarin (BPAC, 2013b) ▫Or Continue dabigatran, more regular renal monitoring (BPAC, 2013b) Self monitoring of blood glucose/medications ▫Or medication management/oversight

11. Mr Green – 75 years old Course of action 1.Stop metformin, start sulfonylurea (NZGG, 2012) 2. Intensive diabetes education with both Mr Green and his wife. 3. Continue on frusemide, review ~1-2 months 4. Continue on dabigatran with more regular renal function checks (BPAC, 2013b)

12. Mr Green, 75 years old Evaluating outcomes Renal function: tested 3-6 monthly in individuals on dabigatran when creatinine clearance is between 30-50ml/min (BPAC, 2013). Effectiveness of sulfonylurea on glycemic control measured through self BGL testing Assessing for hypoglycaemia Monitoring of cardiac symptoms How are Mr and Mrs Green coping?

13. Mr Green, 75 years old Summary Medications are only appropriate if they are appropriate to the person Effectiveness is determined through follow up Medication safety is complex – involve the whole team

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15. References Leese, G. P., Wang, J., Broomhall, J., Kelly, P., Marsden, A., Morrison, W.,... & Morris, A. D. (2003). Frequency of Severe Hypoglycemia Requiring Emergency Treatment in Type 1 and Type 2 Diabetes A population-based study of health service resource use. Diabetes Care, 26(4), 1176-1180. Lipska, K. J., Bailey, C. J., & Inzucchi, S. E. (2011). Use of metformin in the setting of mild-to-moderate renal insufficiency. Diabetes care, 34(6), 1431-1437. Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S. Y. S., Noble, D., Norton, C. A.,... & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’patients. Nurse Education Today, 30(6), 515-520. Medsafe. (2002). New Zealand Data Sheet: Gliclazide. Retrieved from http://www.medsafe.govt.nz/profs/datasheet/a/Apogliclazidetab.pdf http://www.medsafe.govt.nz/profs/datasheet/a/Apogliclazidetab.pdf Medsafe. (2010). New Zealand Data Sheet: Coumadin. Retrieved from http://www.medsafe.govt.nz/profs/datasheet/c/Coumadintab.pdf http://www.medsafe.govt.nz/profs/datasheet/c/Coumadintab.pdf Medsafe. (2011). New Zealand Data Sheet: Metformin. Retrieved from http://www.medsafe.govt.nz/profs/datasheet/m/metformintab.pdf http://www.medsafe.govt.nz/profs/datasheet/m/metformintab.pdf Medsafe. (2014). New Zealand Data Sheet: Dabigatran etexilate. Retrieved from http://www.medsafe.govt.nz/profs/datasheet/p/Pradaxacap.pdf http://www.medsafe.govt.nz/profs/datasheet/p/Pradaxacap.pdf New Zealand Formulary. (2014a). Metformin Hydrochloride. Retrieved from http://www.nzf.org.nz/nzf_3715.htmlhttp://www.nzf.org.nz/nzf_3715.html New Zealand Formulary. (2014b). Dabigatran Etexilate. Retrieved from http://www.nzf.org.nz/nzf_1504.htmlhttp://www.nzf.org.nz/nzf_1504.html

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