Mr X is an 84 year old retired carpenter from Dublin. Mr X has a number of medical problems which are being treated.
Mr X has suffered from Type 2 Diabetes for over 20 years. He is being treated with sitagliptin, gliclazide and insulin. However, his HbA1c is consistently high with latest level of 69mmol/L. He checks his insulin levels regularly and also administers his own insulin. He has never had a hypoglycaemic event.
Although Mr X has attempted in the past to eat healthily and to lose weight, his BMI is still quite high at 31.5. He attends for diabetic review twice a year with his GP. He is also up to date with his retinal screening – his last screen was normal. Mr X has no visual impairment.
Mr X has chronic kidney disease and currently has an eGFR of 31. He suffers from anaemia of chronic disease due to his CKD, which is treated with iron supplements.
Mr X has a history of hypertension which is treated with a beta blocker, alpha blocker, angiotensin-receptor blocker and a loop diuretic. His readings have been stable for the last few months, around 135/70.
Mr X has atrial fibrillation and is treated with dixogin and warfarin. Mr X reports that INR readings are consistently between 2.4 and 2.6. He has noted that his skin heals quite slowly due to his warfarin treatment and is often nervous of injuring himself as a result.
Mr X has osteoarthritis in both knees which was diagnosed in 2015. He has pain that is aggravated by walking long distances. He reports this has been getting worse over the past year. He would not like to avoid using painkillers as he feels that he is taking enough medications and feels like he can handle the pain for now. He does acknowledge that this holds him back from being more active and he doesn’t walk as much as he used to. He also feels like it restricts him around the house, although he still feels he can complete all tasks he wants to. This is the medical problem that bothers Mr X most on a daily basis
Mr X’s past surgical history includes a right hemicolectomy 2008 to remove caecal tumour and surgery to correct an entropion surgery in 1999.
Mr X lives in a two story house with his wife, who is in good health. They are both independent in personal and instrumental activities of daily living, and they have no formal home help. Mr X has 3 children, 2 of whom live in Dublin and visit daily. He has 6 grandchildren. They both drive, but do not have a mobile phone. Mr X’s wife does most of the shopping and food preparation, and Mr X does most of the housework and other practical work around the house. As a retired carpenter, home improvement and general DIY work is Mr X’s main interest and hobby, and is also his main form of exercise. He walks once of twice a week.
Mr X is a lifelong non-smoker and drinks very rarely – on average one pint in a month.
He has never fallen, and has no problems with vision or memory.
Problem List
Poorly controlled DM
Impaired renal function limiting treatment options
Pain of osteoarthritis limiting daily activities
Impaired healing due to DM and warfarin therapy
Comorbidities requiring management by multiple specialties and multiple hospital visits
2. Reflective component
The issue I have decided to explore in relation to this case is the management of Type 2 Diabetes Mellitus. I believe that this is an important topic relevant to primary care as general practitioners are involved in the day-to-day management of this increasingly common chronic illness. I also believe that this is relevant to my patient’s case as he his diabetes management has become increasingly complex over time.
The most recent NICE guidelines on Type 2 Diabetes management were reviewed in an article in the British Medical Journal in 2016.1 This review was accompanied by an excellent chart which lays out the appropriate escalation of treatment depending on the patients HbA1c level, and on whether or not metformin is contraindicated. Initial management is patient education with lifestyle and diet alterations, followed by monotherapy with metformin or an alternative medication, with escalation to dual and triple therapy as needed. It is clear from looking at this chart that there are less treatment options for patients who cannot tolerate metformin.2
This simple chart is a good starting point for anyone looking to manage type 2 diabetes. However, it doesn’t quite take into account the importance of individualising HbA1c level targets depending on patient factors, and on involving the patient in decision making regarding their treatment. This is discussed in more detail in the full text of the NICE guidelines. Individualised care here means an approach to care taking into account multimorbidity, polypharmacy, personal preferences and ability to benefit from intervention. The guidelines also contain recommendations on patient education, dietary advice, control of blood pressure and antiplatelet therapy. I feel this is a valuable resource as it is evidence-based and readily available.3
The ICGP’s “A Practical Guide to Integrated Type 2 Diabetes Care” gives evidence based advice on the management of diabetes and its complications in an Irish context. It also gives a detailed explanation of the shared responsibility between primary and secondary care for the management of the patient, and counsels general practitioners on referral to secondary care and allied health professionals.
This guide contains extensive information on elements of patient education which I think is the cornerstone of diabetes management in terms of improving patient compliance with both lifestyle and medication factors. Regarding HbA1c control, this guide recommends testing every 4 months and treatment adjustment if targets have not been met. 4
The use of metformin has been contraindicated in patients with renal impairment (as with my patient), with congestive heart failure and patients of advanced age (>80 years) due to the risk of lactic acidosis. However, it is important to note that some clinicians believe that the benefits of metformin treatment outweigh these risks. Especially in the case of patients who are at risk of hypoglycaemic events, it is understandable that clinicians would want to use this first line drug that has been of benefit to so many. 5
The most recent guidelines from the American Diabetes Association are in agreement with the NICE guidelines with regards to HbA1c targets – that numerous aspects must be considered and while the goal should ideally be <53mmol/mol, targets need to be individualised to the needs of the the patient. Interestingly, they include a detailed section on screening for comorbidities which include psychiatric disorders such as depression and disordered eating disorders. Older adults over 65 years should be considered a high priority population for screening of depression. I believe that the toll a chronic illness takes on mental health should not be overlooked and therefore think this is a useful addition to the literature. I found the section on diabetes management in older adults particularly useful, as they are a specific patient group with common shared problems. As stated, it is important to consider the time frame benefit of preventive treatment such as lipid lowering and aspirin therapy in this cohort. 6
In Mr X’s case, it is clear from examining the literature that achieving a HbA1c level of 53mmol/mol is not as important as maintaining his overall comfort and quality of life, bearing in mind his comorbidities. Due to his insulin therapy he is being treated in the integrated network between primary and secondary care, and his diabetes management is in keeping with evidence-based guidelines.
3. Medication Review
Efficacy
This patient’s renal impairment means that the dosage of many of his medications needs to be reduced. For example the dosage of sitagliptin has been changed from 100mg to 25 mg od.
Dosage of lispro is also recommended to be reduced in cases of renal impairment.
Mr X’s HbA1c is consistently above the recommended 53mmol/mol. However, due Mr X’s age and comorbidities, we must aim for a personal individualised HbA1c target and focus on his quality of life.
Potential Adverse Reactions and Interactions
Mr X is currently on 4 different medications to treat his hypertension. It is noted in the BNF that concurrent use of any four of these medications can increase the risk of hypotension. Although he has never had a hypotensive episode, it could put him at risk of falls which can be devastating to patient prognosis. It is also noted that doxazosin may effect performance of skill tasks such as driving.
Mr X has also been taking 300mg allopurinol for many years as prophylaxis of gout. In cases of renal impairment, the maximum dose recommended is 100mg. Mr X’s gout is likely iatrogenic due to his treatment with furosemide. As is hypertension is generally well controlled and in light of these interactions and reactions, perhaps these medications can be reviewed.
Mr X is on the maximum dosage of warfarin recommended in elderly patients by the BNF. Of note, INR should be monitored more frequently in the case of renal impairment. Mr X’s INR is very well controlled. The risks of bleeding and delayed healing should be emphasised at reviews.
Of note, this patient has been given a repeat prescription for zopiclone. He has been taking this medication for six months. It is recommended by the BNF to use zopiclone for up to four weeks only, as there is a risk of tolerance and withdrawal in long term use. It is also recommended in elderly patients and in renal impairment to prescribe 3.75mg od, however Mr X is taking 7mg od. I would like to assess whether Mr X still needs medical treatment for sleep or if we could discontinue this medication.
Sitagliptin can cause peripheral oedema, which Mr X has suffered from in the past.
The use of gliclazide in renal impairment is avoided whenever possible, due to risk of hypoglycaemia. Of note, the compensatory response to hypoglycaemia is also impaired in renal impairment. Although Mr X has never had a hypoglycaemic event, the risk of this should be explained to him and reinforced at every review. His glucose monitoring technique should also be checked and discussed with him regularly.
Cost
Mr X has been prescribed the generic forms of most of his medications, which is appropriate. As he is a medical card holder, there is no cost to him thankfully, but the use of generic medications is best practice. For example, by prescribing generic candesartan, this patient can take Blopress at €3.36 per month at just more than a third of the cost of Atacard at €9.16.
Mr X’s most expensive medications are those treating his diabetes. However, these medications are vital and cannot be stopped. It is also vital that Mr X continues to monitor his glucose levels and therefore his test strips, while expensive, are a necessary part of his prescription.
Compliance and Patient Factors
Mr X is self-reported to be very compliant with his medications. In his own words “I just take what they tell me to keep me going.” He is happy to continue with his medications as he enjoys a relatively good quality of life. However, I think it would be worthwhile discussing blister-packing Mr X’s medications with him, and asking the pharmacy if this would be possible. This would save Mr X time as he tries to sort through his many medications each day. This would also avoid any accidental non-compliance if Mr X forgot to take any particular medication.
Mr X has stated that he feels he is on enough medications as it is and is so far unwilling to take pain relief for his osteoarthritis. However, his pain does seem to be negatively impacting his life and impairing his ability to maintain a healthy lifestyle through exercising. It might be worthwhile discussing the use of simple pain relief such as regular paracetamol with him in the future, as this might help his function and improve his quality of life.