Advanced Pharmacology Diabetes Homework Points: 25 Comments: Name: Tracy Hill WU ID #: 20015608 E-mail: tracy.hill@washburn.edu _TH I hereby certify that the work submitted is my own, and that I have not plagiarized or violated any terms of the WU School of Nursing s Classroom NOTE: You must insert your initials in the area of the line on the right Integrity Policies. LF is a 66yo WM presenting to clinic for management of his multiple disease states including Type 2 DM. His past medical history is remarkable for 2 vessel CABG (1999), HTN, depression and Type 2 DM (since 1995). He currently complains of swollen ankles, weight gain and mild shortness of breath. He is adherent with his medications but does not follow a formal diet and exercise regimen. Current Medications: Metformin 1000 mg BID Simvastatin 40 mg daily Actos (pioglitazone) 30 mg daily Citalopram 20 mg daily ASA 81 mg daily Lisinopril 10 mg daily Januvia (sitagliptin) 100 mg daily PMH: Obesity Hypertension CABG Type 2 DM Depression PE: 2+ pitting edema (ankles) Vitals: BP 142/82 Weight 92kg Pulse 70 SH: (-) etoh (+) tobacco (2PPD) Occupation: Retired Married with 3 children FH: (+) Hypertension (mother, brother) (+) Dyslipidemia (mother, brother) Laboratory: Random BG 245mg/dl HbA1c 9% SCr 1.1 mg/dl 1. Which drug is likely contributing to his symptoms, explain? What should be done to manage his complaints? (5 points) Points: 5 Comments: Good! Actos is the drug that is likely to be contributing to his symptoms. This drug may cause a substantial increase in weight gain that is due in part to fat or fluid retention
(Edmunds & Mayhew, 2009, p.574). There is a black box warning for Actos that states: May increase risk for ischemic events. Monitor for signs and symptoms of CHF, especially edema and or dyspnea, which this pt is currently exhibiting (Edmunds & Mayhew, 2009). Plan of action: Stop the Actos. Initiate insulin therapy and education (Lantus) Discuss Smoking Cessation (2ppd smoker). Continue to recommend pt follows ADA diet for diabetes control.
2. Since your patient appears to be motivated and willing to get his blood sugars under control, you decide that a trial of a long-acting insulin might be in order. Using the prescription form below, write for an appropriate product (Teaching the patient how to use it, etc., will be done by the diabetes educator and the pharmacist). (10 points) Points: 10 Comments: Primary Care Associates, Inc. 1020 Wellness Road Resume Speed, KS (913) 123-4567 Name LF Date 4/6/2011 Address 1234 Maine St City/State/Zip Lawrence, KS 66044 Rx Lantus 100u/ml Disp: 1 vial 10 units every night at bedtime Age/Wt 66 / 92kg [ ] [ T. Hill, ARNP ] Dispense as Written NOTE: This is a sample prescription form which is Substitution Permitted Refills none to be used for practice only. The contents hereon is not a valid prescription for any medication. DEA # (Taketomo, Hodding, & Kraus, 2008).
3.With all insulins, including the long-acting peakless insulins, there is a risk of hypoglycemia. What education will you give your patient regarding hypoglycemia, its symptoms, and treatment? BE CONCISE!!! (10 points) Points: 10 Comments: Hypoglycemia is the most common adverse reaction of insulin, including Lantus. Hypoglycemia happens when the amount of blood glucose in the body has dropped below 4 mmol/l. Hypoglycemia is an emergency situation. It can happen within minutes of the patient appearing healthy and normal, so it is important to take care of it right away. The risk of hypoglycemia increases with intensive glycemic control. Patients must be educated to recognize and manage hypoglycemia. Severe hypoglycemia can lead to unconsciousness or convulsions and may result in temporary or permanent impairment of brain function or death. Severe hypoglycemia requiring the assistance of another person or parenteral glucose infusion or glucagon administration is possible. The signs of hypoglycemia include: cold, clammy or sweaty skin; pallor; difficulty concentrating; shakiness, lack of coordination; irritability, hostility, and poor behavior; a staggering gait; fatigue; nervousness; excessive hunger; headache; blurred vision and dizziness; abdominal pain or nausea, fainting and unconsciousness. The timing of hypoglycemia usually reflects the time-action profile of the administered insulin formulations. Other factors such as changes in food intake (e.g., amount of food or timing of meals), exercise, and concomitant medications may also alter the risk of hypoglycemia. The prolonged effect of subcutaneous Lantus may delay recovery from hypoglycemia. Patients being switched from oral medications to once-
daily Lantus should have their initial Lantus start at 10 units daily, at the same time of day, for example 10 units at bedtime, to reduce the risk of hypoglycemia. As with all insulins, use caution in patients with hypoglycemia unawareness and in patients who may be predisposed to hypoglycemia (e.g., the pediatric population and patients who fast or have erratic food intake). The patient's ability to concentrate and react may be impaired as a result of hypoglycemia. This may present a risk in situations where these abilities are especially important, such as driving or operating other machinery. Early warning symptoms of hypoglycemia may be different or less pronounced under certain conditions, such as longstanding diabetes, diabetic neuropathy, use of medications such as beta-blockers, or intensified glycemic control. These situations may result in severe hypoglycemia (and, possibly, loss of consciousness) prior to the patient's awareness of hypoglycemia. Instruct the patient and family members on the treatment of hypoglycemia. Some suggestions for the treatment of hypoglycemia includes, but is not limited to: 15 g of glucose in the form of glucose tablets or 15 ml (3 teaspoons) or 3 packets of table sugar dissolved in water, or 175 ml (3/4 cup) of juice or regular soft drink or 6 Life Savers (1=2.5 g of carbohydrate), or 15 ml (1 tablespoon) of honey. Wait 10 to 15 minutes, if there is no improvement, treat again. The patient and family members should carry oral glucose tablets or other treatment options with them at all times in case of hypoglycemic episodes. Always make sure you have a glucose meter available to closely monitor glucose levels. Education of
family members is also important, so they can recognize the signs and symptoms of hypoglycemia and treat the patient quickly and appropriately.
References Edmunds, M. W., & Mayhew, M. S. (2009). Pharmacology for the primary care provider (3rd ed.). St.Louis, MO: Mosby. Taketomo, C. K., Hodding, J. H., & Kraus, D. M. (2008). Pediatric Dosage Handbook (15th ed.). Hudson, OH: Lexi-Comp.