MM+401+-+1

=Case 1 - Albert Page=

//Albert Page is a 79 year old man who lives at home with his wife. He requires a review of his diabetes regimen.//

• Frequent urine dribbling experienced, inability to completely empty bladder • Stomach cramps experienced over the last month. • Insomnia
 * Current symptoms:**

• Diabetes (Type 2) • Hypertension • Hypercholesterolaemia • Depression • Fractured hip • Nasal congestion
 * Medical history:**

• Creatinine 122 micromol/L (45-90 micromol/L) • Urea 10 mmol/L (2.5-7.7mmol/L) • Blood pressure 145/95 mmHg (130/85 mmHg) • Random BSL 9.2 mmol/L (4-8 mmol/L) • Albumin: 50g/L (32-42g/L) • HbA1C 7.8% (<7%) • Total Cholesterol 6.5 mmol/L (<5.5mmol/L) • LDL 4.3mmol/L (<3.7mmol/L)
 * Test Results from one month ago (excluding values inside the range):**

**
 * Current medications:

Problems
- inability to complete bladder may be due to amitryptyline (TCA) or diabetes (neuropathy and frequent urination from osmotic effect due to high BSL), or benign prostatic hyperplasia - stomach cramps may be due to metformin (if lactic acidosis from renal impairment - tell doctor immediately) or alendronate (incorrect administration) - insomnia due to phenylephrine? or tolerance to temazepam's effects; uncontrolled depression or lack of sleep hygeine (although amitryptyline should help aid sleep)
 * Current symptoms:**

- BMI = 24 (normal) - high creatinine and urea indicate decreased renal function (CrCL around 40mL/min - mild impairment) - blood pressure is high - blood sugars and HbA1C are high - albumin is high (may indicate dehydration?) - TC and LDL are high
 * Test results:**

Temazepam - tolerance (reserved for short-term use): unnecessary exposure to side effects - increased sensitivity to CNS effects in renal impairment - risk of sedation/falls (fractured hip) //Metformin// - using metformin when renal function has declined - may be causing cramps //Glibenclamide -// risk of hypoglycaemic attack especially in the elderly (falls) - increased risk in renal impairment //Simvastatin// - no need to increase simvastatin dose (already exerting most of its effect at current dose) + may need combination with ezetimibe (10mg d - require LFTs and monitor muscle symptoms) //Metoprolol// - drug interaction: metoprolol and diabetes (reduces signs of a hypoglycaemic attack) + could switch to ACEi or ARB Alendronate - should not be taken at night before bed (best in morning before breakfast while standing up to reduce stomach upsets) - not recommended CLcr<35mL/min (monitor renal) - ADR: gastritis //Calcium/Vitamin D// - low dose? - ensure that it is not taken with alendronate //Omeprazole -// best to treat cause of stomach problems - not the best treatment as it is a stomach cramp + use anti-spasmodic such as hyoscine //Amitryptyline// - can affect BSL - urinary retention, stomach cramps - risk of sedation/falls (fractured hip) + switch to TCA with less anti-cholinergic effects (nortryptyline) //Phenylephrine// - affects BP, increases alertness (insomnia) + could possibly switch to anti-histamines/corticosteroids if symptoms are hayfever + could switch to saline //Valerian Forte// - ADR: mild GI symptoms over 500mg - additive sedation (falls)
 * Current Medications:**

- compliance with diabetic medications - BGL checks are rarely performed (may not know whether undergoing a hypo etc.) + need to increase exercise (difficult with fractured hip) + improve diet
 * Other problems:**

= =

What to do
adverse drug reaction || Alendronate 70mg (1 on Monday) //takes at night before bed// || - due to inappropriate administration of alendronate? - possibly due to lactic acidosis? + review the use of omeprazole as it will be an unnecessary therapy if it is used to treat alendronate-induced stomach discomfort || adverse drug reaction need for additional therapy || Amitryptyline 50mg (2 n) || - side effect of TCAs - can cause urinary retention (anticholinergic effect) - possibility of untreated disease e.g. benign prostatic hyperplasia, requiring GP examination + substitute for nortryptyline (decreased anticholinergic effect) || ineffective drug adverse drug reaction || Temazepam 10mg (1-2n) //takes 2 every night even though it doesn't work anymore// Blackmore's Valerian Forte (valerian extract) (1 n prn) //takes every night// || - ineffective drug (not producing desired response) - drug interaction: valerian and BZD, may cause CNS depression or an accumulative sedative effect || compliance need for additional therapy || Metformin 500mg (1 bd) Glibenclamide 5mg (1 d) || - random BSL of 9.2mmol/L and HbA1c of 7.8% - rarely performs BGL checks - potential risk of lactic acidosis due to age and mild renal impairment + emphasise importance of regular BGL checks and lifestyle modification + only consider other treatments (insulin or combination of oral drugs) if above strategy fails || need for additional therapy || Metoprolol 100mg (1 bd) || - need for additional therapy (add ACEi?) - phenylephrine increases BP + educate on importance of prn usage of the medication + could substitute phenylephrine with saline || additional drug therapy || Simvastatin 40mg (1 n) || - the patient has high cholesterol and LDL level + encourage healthy diet and increased physical activity + consider adding ezetimibe (10mg d) + monitor LFT and muscle symptoms ||
 * **Drug Related Problem** || **Current Treatment** || **Comments** ||
 * //__1. Stomach cramps experienced over the last month__//
 * //__2. Urine dribbling and inability to completely empty bladder__//
 * //__3. Insomnia__//
 * //__4. Poor control of blood sugar level__//
 * __//5. Uncontrolled hypertension//__
 * //__6. Poor control of cholesterol level__//