Question

     Drugs Affecting Blood Glucose Levels

CASE STUDY

Joseph Sanchez is a 70-year-old Hispanic man who presents to for a 3 month follow up visit. He states that he has been experiencing nocturia several times each night and increased hunger and thirst for the past month. He denies signs and symptoms of hypoglycemia. He is very concerned that his diabetes is not controlled. In reviewing his medication profile, he had been on glipizide which had been gradually increased over the past year to the maximum recommended daily dose of 40 mg/day. He was recently started on empagliflozin on his previous visit. His past medical history includes Type II diabetes mellitus (diagnosed 15 years ago), hyperlipidemia, chronic gouty arthritis, COPD, and HTN.

Data Obtained from Nursing Assessment

• Weight: 215 pound, Height 5feet, 4 inches, BMI 36.9
• Vital signs: temperature, 37.1°C; pulse, 71; respiration, 18; blood pressure, 112/72
• HEENT: PERRLA, discs flat—no hemorrhages or exudates; TMs intact; oral mucosa within normal limits
• Neck: thyroid within normal limits
• CV: NSR, normal S1 and S2; no murmurs, rubs, or S3 or S4 gallop
• Lungs: A & P clear
• Abdomen: soft, obese, BS all four quadrants, healed midline incision, no hepatosplenomegaly, complains of “nausea, bloating”
• MS/Extremities: pulses 2+, no joint aches/pains
• Neuro: A & O X 4, CN II–XII intact, DTRs (deep tendon reflexes) 2+
• History of smoking—40 pack-years
• Denies alcohol intake
• Walks three to four blocks around neighborhood one to two times per week

Lab Data

• Total cholesterol: 315 mg/dL (LDL: 238 mg/dL, HDL: 30 mg/dL)
• Triglycerides: 218 mg/dL
• Glucose: 303 mg/dL (Accucheck), 361 mg/dL (fasting); HgbA_1C: 13% (5 months ago) prior to medication change
• Electrolytes: sodium: 137 mEq/L, potassium: 3.8 mEq/L, chloride: 95 mEq/L
• BUN: 22 mg/dL
• Creatinine: 1.1 mg/dL

Current Drug Therapy

• Metoprolol 50mg PO daily
• Furosemide 80 mg PO daily
• Jardiance (empagliflozin) 10mg daily
• Indomethacin SR 75 mg PO daily prn
• Ipratropium bromide MDI two puffs four times daily
• Prednisone 20mg PO daily
• Albuterol metered-dose inhaler (MDI) two puffs as needed

CONSIDER THE CORE PATIENT VARIABLES FOR THIS DRUG:

( consider the patient history including past medical history, social history, lifestyle etc.)

What patient variables are most important to consider for Mr. Sanchez when assessing his drug therapy? Address each of his conditions and related medications

What additional data (diagnostics etc.) is needed to determine proper drug therapy?

Which of the findings from the assessment demonstrate effectiveness of his drug therapy?

Which of the findings from the assessment demonstrate possible adverse effects from drug therapy?

CONSIDER THE MANAGEMENT NEEDED WITH THIS DRUG THERAPY

What teaching is required for Mr. Sanchez regarding each of his medications for each of his diagnoses?

Answer 1

Question 1. The variables to be considered. As per the data obtained from the history and physical examination it is clear that he is compliant to follow up and medication and non compliant life style modification.

He is over weight with a BMI of 36.9 kg/m2. From the lab data it is clear that he is taking a unhealthy diet. To tal cholesterol of 315,glucose 303 and HbA1c of 13 %. He walks barely 2 times a week. As we are all aware management of diabetes does not depend only on medication. It is a comprehensive goal that the patient should achieve. Medication, diet, regular follow up and exercise plays a major role.

Medication and related disease.

Hypertension.

Metoprolol =beta 1 selective adrenergic blocker group of antihypertensive.

Frusemide= a loop diuretic.

Diabetes mellitus.

Glipizide. Sulphonyl urea anti Diabetic drug.

Empagliflozin. sodium-glucose co-transporter 2 (SGLT2) inhibitors.

Gouty arthritis

Indomethacin. Non steroidal anti inflammatory drug to relieve pain.

COPD. ipratropium bromide, albuterol puffs.

Prednisone cortico Steroid.

Investigation can be included

Liver function test.

Findings indicate effectiveness.

BP of 112 /80 mmhg normotensive indicating efficacy of antihypertensive therapy.

Has controlled COPD as observed normal lung sounds and normal respiration.

Controlled arthritis pain.

Adverse effects from drug therapy.

Uncontrolled diabetes. Steroid induced due to prednisone

Nocturia due to frusemide

Glipizide weight gain, nausea and bloating.

Drug to be included hmg Co a reductase inhibitor or statins to lower serum cholesterol levels.

Teaching.

Metaprolol. Taking daily at same time, monitor blood pressure, not to stop without doctors order

Frusemide to be taken at 8 am and 4 pm to prevent disturbed sleep due to diuresis.

Prednisone. Diet to be controlled, and should not be stopped abruptly.

Ipratropium bromide and albuterol to be used with spacers.