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 DRUG KNOWLEDGE FOR EACH OF THESE DRUGS

Provide the following information for each drug that the Ms. Sanchez is taking:

Action, Indication for use, Therapeutic dosage, Contraindications, Adverse Reactions

Drug/Drug Interaction related directly to the current drug regime (do not list all drug/drug interactions if not applicable)

Based on the new ADA guidelines and her current health status, what other antidiabetic drugs could be used to treat Mr. Sanchez’s Type II diabetes?

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

CONSIDER THE CORE DRUG KNOWLEDGE FOR EACH OF THESE DRUGS

Metoprolol

Action:- selectively inhibits beta adrenergic receptors.

Indication for use:- Hypertension,prevention of reonfarction of MI,long term treatment of angina pectoris.

Therapeutic dose:-hypertension and angina pectoris - 100 mg/ day in single or divided doses,maintenance up to 100-450 mg/day.

Post MI - 100 mg/ bid and can continue at least 3 months.

Contraindications :- 2nd or 3 rd degree AV block, sick sinus syndrome,decompensated heart failure,cardiogenic shock,asthma,pheochromocytoma,metabolic acidosis,pregnancy.

Adverse reactions :-bradycardia, hypotension,arterial insufficiency,chest pain,palpitation,syncope,confusion,depression,fatigue,pruritus,short term memory

loss,insomnia,sexual dysfunction,constipation,flatulence,nausea,musculoskeletal pain,blurred vision,dry eyes,tinnitus,wheezing,cold extremities, bronchospasm,heart failure.

Drug interaction:- Furosemide; it will lower the blood pressure and cause weakness

Pednisone; prolonged use of prednisone can lower the effect of metoprolol due to low blood pressure.

FUROSEMIDE

Action:- loop diuretic,inhibits reabsorption of sodium and chloride in the loop of Henley.

Indication for use:- CHF,cirrhosis,renal disease,acute pulmonary edema, hypertension.

Therapeutic dose:20-80 mg/day in single dose initially for edema in adults.

Hypertension, 40 mg/bid

Acute pulmonary edema, 40 mg iv over 2 min

Contraindications :- Severe sodium and water depletion, hypersensitivity to sulphonamides and furosemide,hypokalemia,hyponatremia,renal failure and addison's disease.

Adverse reactions :-fluid and electrolyte imbalances, photosensitivity,blurred vision, nausea,hypotension,headache,dizziness,glycosuria,cytotoxicity,hypokalemia,cardiac arrythmia.

Drug interaction:- metoprolol; it will lower the blood pressure and cause weakness

Albeuterol; It can cause hypokalemia.

JARDINACE

Action:- inhibits reabsrption of glucose from the tubular lumen.

Indication for use:- type 2 diabetes mellitus

Therapeutic dose:10 mg /day or can increase to 25 mg/day

Contraindications :- Hypersensitivity,renal impairment,diabetic keto acidosis,lactation

Adverse reactions :-ketoacidosis,urosepsis,hypoglycemia,hypotension,hyperlipidemia

Drug interaction:- metoprolol; it will lower the blood pressure and cause weakness

furosemide ; it can cause acute kidney injury

INDOMETHACIN

Action:- NSAIDs

Indication for use:- rheumatoid arthritis,spondilytiscystoid macular edema

Therapeutic dose:25mg bid or up to 500 mg /daily for arthritis.

Acute painful shoulder: 75-150 mg/day

Contraindications :- Allergy, GI bleeding,bypass surgery,proctitis,pregnancy,thrombocytopenia

Adverse reactions :-nausea,vomiting,heart burn,diarrhoea,constipation,dizziness,tinnitus,chest pain

Drug interaction:-furosemide;it lowers blood pressure

PREDNISONE

Action:- cortico steriods

Indication for use:- arthritis,blood disorders,breathing disorders,severe allergies,skin disorders

Therapeutic dose:5-60 mg /day

Contraindications :- Allergy, GI bleeding,bypass surgery,proctitis,pregnancy,thrombocytopenia

Adverse reactions :-nausea,vomiting,heart burn,diarrhoea,constipation,dizziness,muscle cramps,unusual weight gain,hyperglycemia,blurred vision,allergic reactions

Drug interaction:-nil