Reason for referral: provide patient education on management of hypoglycemia and glucose monitor

Transcription

1 Meet Robin Sawyer (otherwise known as PT 1): Let s Create a Care Plan! Reason for referral: provide patient education on management of hypoglycemia and glucose monitor History of present illness: yo lawyer, 6 2, 210 lbs (BMI 27), diagnosed with type 2 diabetes 6 yrs ago. His GP recently started long acting insulin glargine (Lantus ) once daily at bedtime. Robin was instructed to check his blood glucose more often. With his busy lifestyle and work schedule, Robin doesn t feel he ll be able to do it. He is unsure of how often and what times of day. He finds it difficult to have a meter with him at all times (home, office, court, lunch meetings). Sometimes, he doesn t know if the strips are expired and if they can be used past the expiration date. He is worried he experienced a couple episodes of low blood sugar (based on dizziness) in last week, yet he could not verify. He wants to know if testing all the time is necessary and what the latest research says. Past Medical History: Dyslipidemia HTN DM No history of CVD Tonsillectomy at age 2 7 Leg fracture, age Medication Allergies: NKDA Medication History: Indication Drug Name Directions Adherence (Y/N) Notes/Comments Diabetes Metformin 1000 mg BID (AM and supper) Y, except noon Taken x 6 years 500 mg at noon dose often missed Diabetes Gliclazide 80 mg BID (AM and supper) Y Taken x 5 years Diabetes Insulin glargine (Lantus ) 10 units qhs Y Started 1 month ago; tolerating injections Hyperlipidemia Atorvastatin 10 mg QHS Y Taken X 2 years Hypertension Ramipril 10 mg QAM Y Started 3 years ago No OTC use (and specifically does not take aspirin) Receives yearly influenza vaccine Organizes medications himself; does not use dosette or blister pack Generally remembers to take his medications Is not bothered that he takes chronic medications; generally feels well except for some recent dizzy spells Social History: (+) smoking: 5 6 cigarettes/day x past year (1ppd x 20 years prior to this), cigar on the weekend at the country club. Tried quitting in the past but the stress of the job makes it difficult. Diet: eats breakfast and supper routinely; sometimes misses lunch due to busy schedule. Tries to eat DM diet. EtOh: nil Occupation: lawyer Married, 2 teenage children Family History: (+) diabetes maternal grandmother, father Strong family history of heart disease (Dad, MI, age 50; Mom, stroke, age 60)

2 Review of Systems CNS: occ. light headedness and dizziness which he thinks may be associated with low FPG from skipping meals, but does not check with meter. No HA reported. CVS: BP (MD office last week) 128/80, HR 70 bpm; does not use home BP monitor Resp: no concerns Abdo: mild central obesity, lost 30 lbs in last 6 yrs since diagnosed with DM. Normal BM; no N/V General: overall, has increased stress related to his occupation. Investigations Labs (taken last week as per physician request) Parameter Actual Normal Range Na 142 mmol/l mmol/l K 4.1 mmol/l mmol/l Scr 102 umol/l umol/l BUN 4.3 umol/l LDL 1.66 mmo/l Treatment Goals HDL 1.13 mmo/l T CHol 4.09 mmo/l Trig 2.87 mmo/l Total:HDL 3.6 ALT 15 U/L < 50 U/L AST ALP T Bili A1C 7.9 % % FPG 7.7 mmol/l mmol/l Hgb 136 g/l g/l WBC 5.2 x 10 9 /L 4 11 x 10 9 /L Urine Microalbumin/Creatinine ratio 0.1 mg/mmol < 2.0 mg/mmol For all patients, a primary target is a reduction of greater than or equal to 50% in the LDL cholesterol value. For patients classified as high or moderate risk, the primary target is a reduction of greater than or equal to 50% in the LDL cholesterol value or a LDL of < 2.0 mmol/l.

3 PHARMACY CARE PLAN WORKSHEET Robin Sawyer MEDICAL CONDITION AND/OR DRPs DM 1. Requires education about blood glucose monitoring (BGM) to use insulin safely 2. Appears to be experiencing hypoglycemia (dizziness) when meals skipped 3. A1C 7.9 which is suboptimal for him 4. Lifestyle and CV risk factors given he has DM see below GOALS OF THERAPY ALTERNATIVES RECOMMENDATIONS/ PLAN 1. Educate on importance of glucose monitoring for using insulin safely, and link between insulin use and potential for hypoglycemia. 2. Determine if dizziness caused by hypoglycemia. 3. Goal A1C<7: need to review BG pattern to see if patient is meeting ac and pc BG targets; need to minimize hypoglycemia while achieving this. 1. Education on glucose monitoring; No alternatives stress importance of BGM while on insulin and discuss strategies to implement 2. No alternatives; need to definitively determine if hypoglycemia is occurring *Consider hypotension as alternate explanation for dizziness. 3. Goal A1C while minimizing dizziness a. Based on ac and pc BG and A1C, may need to optimize insulin/oral regimen 1. Encourage BGM (qid initially including ac and pc lunch) to determine if low BG are likely causing dizzy spells. Use journal to track. Provided info on strips and expiry. New strips provided. 2. Suggested ways today to treat hypoglycemia if present (based on BGM) a. Sugar candies b. Eating regular meals 3. Sold additional (small) BGM for use in office (he didn t realize small monitors available) MONITORING PARAMETERS Short term: # of dizzy spells, when they occur, corresponding BGM data to confirm if dizziness is related to low BG Long term: address achieving A1C goal and modification/intensification of therapy to achieve this. Review BG levels once using a BGM. Re check A1C in 3 months (insulin newly started). CV Risk Assessment (Framingham 2008 version): high risk for primary prevention based on age <45 + DM and 3 other risk factors (HTN, smoking, positive family history) Dyslipidemia 1. LDL<2mmol/L: goal achieved None required goal met. (LDL Tolerability of atorvastatin mmol/l) 3. Adherence HTN Last BP reading 128/80 1. Goal < 130/80 (DM) 2. Implement Home BP Monitoring (HBPM) 3. Tolerability of ramipril 4. Adherence None required at this time goal met. (128/80) Ensure home BPs are controlled. 1. Continue atorvastatin 10 mg daily as prescribed. 2. Tolerating well (specifically no myopathy), ALT normal 1. Continue ramipril 10 mg daily 2. Tolerating ramipril, K+ 4.1, Scr 102 (unchanged from 1 yr ago), ACR N 3. Recommend purchasing home BP monitor in future 1. Alert us if concerns arise 2. Ensure LDL<2 mmol/l maintained annually 3. Adherence Deferred; patient will try HBPM in future once DM better controlled FOLLOW UP Short term: How: phone or in person depending on Robin s schedule When: 1 2 weeks Long term plan will be determined based on data gathered for current issue. Who: he will call if problem How: phone/person When: every 3 6 months for adherence, annually for lipid profile How: next inperson visit When: 1 4 months ASA indication for use? To reduce CV events, namely MI, while minimizing risk of bleeding 1. Aspirin mg daily PRO: will reduce total CV events by 12%, and MI by 23%. Given high risk status, he may benefit IF his risk of GI bleeding is low. Would need to explore next visit CON: No evidence in DM currently that dictates use of ASA without evidence of CVD, overall event rate low based on age, bleeding risk increased (GI and ICH) 1. Defer; will discuss with Robin next time we meet. Need to discuss bleeding history. Interest in using ASA after discussing benefits/risks with him. How: next inperson visit When: 1 4 months

4 Lifestyle changes 1. Smoking 2. Diet/weight 3. Exercise regimen 1. Assess readiness to quit smoking 2. Review diet/eating pattern and reinforce importance of losing weight (or not gaining weight) 3. Implement 30 minutes/day 3x/week (Robin feels this is doable) 1. Assessment/discussion of readiness versus no discussion depending on time frame 2. Suggest ways to incorporate eating through day to minimize hypoglycemia; promote DM diet 3. Discussed types of activities he likes: walking, tennis, biking 1. Not interested in quitting at this time; will consider in future. 2. Will try and have snacks/preprepared meals on hand for convenience 3. Will exercise starting 3x/wk 1. Smoking readiness toquit; discuss in future 2. Success of dietary changes 3. Success of exercise pattern How: next visit When: 1 2 months; focus on smoking cessation as he would like to achieve this in future

5 Example of Initial Consult Note Robin Sawyer (otherwise known as PT 1) DATA Reason for Referral: provide patient education on management of dizziness (?hypoglycemia) and home glucose monitor HPI: yo lawyer, 6 2, 210 lbs (BMI 27), diagnosed with type 2 diabetes x 6 yrs GP recently started long acting insulin glargine (Lantus ) HS. Instructed to check his blood glucose more often. With his busy lifestyle and work not been able to do it. He is unsure of how often and what times of day. He finds it difficult to have a glucometer with him at all times (home, office, court, lunch meetings). Also concerned strips are expired and wants to know if they can be used past expiration date Worried he experienced a couple episodes of low blood sugar (based on dizziness) in last week in early afternoon after skipping lunch, yet he could not verify. Wants to know if testing all the time is necessary and what the latest research says. Relevant Past Medical History: Dyslipidemia, HTN, No history of CVD Medication Allergies: NKDA Medication History: Indication Drug Name Directions Adherence (Y/N) Notes/Comments Diabetes Metformin 1000 mg BID (AM and supper) Y, except noon dose Taken x 6 years 500 mg at noon often missed Diabetes Gliclazide 80 mg BID (AM and supper) Y Taken x 5 years Diabetes Lantus insulin 10 units qhs Y Started 1 month ago; tolerating injections Hyperlipidemia Atorvastatin 10 mg QHS Y Taken X 2 years Hypertension Ramipril 10 mg QAM Y Started 3 years ago No OTC use and does not take daily aspirin; receives yearly influenza vaccine Med Management: organizes medications himself; does not use dosette or blister pack Social History: (+) smoking: 5 6 cigarettes/day x past year (1ppd x 20 years prior to this), cigar on the weekend at the country club. Tried quitting in the past but the stress of the job makes it difficult. Not interested in quitting at this time. Diet: eats breakfast and supper routinely; sometimes misses lunch due to busy schedule. Tries to eat DM diet. Family History: (+) DM maternal grandmother, father (+) family history CAD (Dad, MI, age 50; Mom, stroke, age 60) Review of Systems CNS: occ. light headedness and dizziness which he thinks may be associated with low FPG from skipping meals, but does not check with meter. No HA reported. CVS: BP (MD office last week) 128/80, HR 70 bpm; does not use home BP monitor Abdo: mild central obesity, lost 30 lbs in last 6 yrs since diagnosed with DM. Normal BM; no N/V

6 General: overall, has increased stress related to his occupation. Investigations Labs (taken last week as per physician request) Parameter Actual Normal Range K 4.1 mmol/l mmol/l Scr 102 umol/l umol/l LDL 1.66 mmo/l < 2 mmol/l ALT 15 U/L < 50 U/L A1C 7.9 % % FPG 7.7 mmol/l mmol/l Urine Microalbumin/Creatinine ratio 0.1 mg/mmol < 2.0 mg/mmol ASSESSMENT/PLAN 1. Education on proper blood glucose monitoring and its importance provided, especially when using insulin and experiencing dizziness. a. Agrees to purchasing new, small glucometer for use in the office b. Will record his FBG readings for review by pharmacist in 2 weeks. c. Important to check the glucose 3 4 times a day when insulin regimen is new, especially during episodes of dizziness and if insulin dose changes. If can only check bid, best times would be ac breakfast and hs. 2.?Hypoglycemia; obtain FBG readings periodically as well as during dizzy spells to verify if this is actual cause a. Avoid skipping lunch and try to have 6 small meals spread throughout day. b. Carry dextrose tablets or hard candies and use if feeling dizzy and FBG is low (less than 3.5 mmol/l) 3. Optimize A1C to less than 7 over next 3 6 months; A1C currently 7.9 a. Assess drug options after viewing FBG records b. Insulin dose may need to be changed; consider more intensive regimen c. Repeat A1C when appropriate in future 4. CV Risk Assessment high risk based on Framingham and UKPDS. Needs aggressive control of modifiable risk factors. a. Smoking cessation: defer. Aware of options to support him in quitting. b. Weight loss encouraged; goal BMI<25. Referral to dietician made. c. BP: goal less than 130/80. Suggest HBPM for use in future to ensure goal maintained. Follow Scr as elevated, but not different from baseline 1 year ago. K+ normal. ACR normal. d. LDL goal less than 2mmol/L; no change to atorvastatin as goal of less than 2 mmol/l achieved, ALT normal, tolerating atorvastatin well. e. Consider ASA therapy in future. FOLLOW UP: 1 2 weeks for reviewing FBG records and # dizzy spells. Will optimize his DM management then. Consider discussion of HBPM, smoking cessation and ASA.

7 Example Short Documentation for INTERNAL PHARMACY USE DATA yo with DMII, started on insulin glargine hs 1 month ago. Concerned about dizziness (?hypoglycemia) that occurs after skipping lunch. Also wants to know about use of home glucose monitor. HPI: Instructed to check blood glucose more often; with busy lifestyle, not happening. Unsure of how often and when. Difficult to have a glucometer with him at all times (home, office, court, lunch meetings). Relevant PMHx: Dyslipidemia, HTN, No Hx of CVD Medications (NKDA): metformin 1000 mg bid mg lunch, gliclazide 80 mg bid, insulin glargine 10 units hs, atorvastatin 10 mg daily, ramipril 10 mg qam. 100% adherent with all except noon metformin (occ. misses), No OTC use. No ASA use. Tolerates all meds. Cardiac Risk Factors: HTN (BP 128/80), DM, dyslipidemia, (+) smoking (5 6 cigarettes/day x past year, not interested in quitting at this time), +FHx CAD, Diet: sometimes misses lunch, lost 30 lbs in last year. Relevant Labs: K+ 4.1, Scr 102 (similar to Scr 1 year ago), LDL 1.66, ALT 15, A1C 7.9 ASSESSMENT/PLAN 1. Education on proper blood glucose monitoring and its importance provided, especially when using insulin and experiencing dizziness. a. Buys new monitor for use in the office, will record his FBG readings, important to check the glucose tid qid, (both ac and pc meals) esp during episodes of dizziness and if insulin dose changes. If only check bid, try ac breakfast and hs. 2.?Hypoglycemia; obtain FBG readings during dizzy spells to verify if this is actual cause a. Avoid skipping lunch and carry/use dextrose tablets/hard candies if feeling dizzy and FBG low (less than 3.5 mmol/l) 3. Goal A1C to less than 7 over next 3 6 months; Repeat A1C when appropriate 4. CV Risk Assessment high risk based on Framingham and UKPDS. Control modifiable risk factors. a. Smoking cessation: deferred b. Weight loss encouraged; goal BMI less than 25. Referral to dietician made. c. BP: goal less than 130/80. Suggest HBPM for use in future. Follow elevated Scr. K+ normal. d. LDL goal less than 2mmol/L achieved F/U: 1 2 weeks for reviewing FBG records and # dizzy spells. Optimize DM management then. Consider HBPM, smoking cessation and ASA.