Pharmacy Office Visit 09-10-12

S: Ms. Betes is a 67 yo WF seen today in diabetes clinic. Accompanied by her daughter Jessica to the appt. PMH: type 2DM, HTN, hyperlipidemia, AFib on chronic anticoagulation, OA, and COPD. FH:  type 2 DM and MI in mother (deceased), stroke in father (deceased). SH—retired school teacher, lives with her daughter; denies EtOh use; admits to smoking 4 to 5 cigs/day; 7.5 pack-yr history, unsure about quitting. Allergies: penicillin (anaphylaxis as child). Today her primary concern is uncontrolled diabetes despite increases in her insulin therapy; she brings in her BG log which reveals elevated post-prandial values and periodic elevated fasting BG. Admits to nocturia 2-3 times per night and difficulty with drawing up insulin injections due to OA in hands. Also c/o of high cost of Januvia, which was recently added to her regimen. Admits to some bruising at injection site which prompted her to hold 2 doses of her Coumadin. Denies any s/sx of bleeding. Stopped statin therapy ~ 6 months ago due to concerns of increased risk of DM with statins. Taking Spiriva 2-3 times per week as needed for SOB. Limited physical activity due to OA pain (pain 4/10 today, worst 6/10, best 0/10), began using ibuprofen 200 mg (OTC) 1 to 2 tablets daily at bedtime with some relief, reports poor relief with acetaminophen up to 3 grams per day. Dietary review reveals occasional skipped meals with intake of sweetened snacks and beverages. Relies on daughter for meal planning.

O: Today: VS: BP: 128/74 mmHg, Pulse: 64 bpm, RR: 16, Ht: 5’6”, Wt: 201 lbs, Sp02: 98%

INR (POCT) today=1.6    08/02/12: Hemoglobin A1c: 9.3%, TC: 201 mg/dl, HDL: 43 mg/dl, TG: 224 mg/dl, LDL (calc): 113 mg/dl,  Glucose: 166 mg /dl, Creatinine: 0.57 mg/dl, Potassium: 3.8 mmol/L, remainder of CMP WNL. INR (POCT)=2.3    07/12/12: INR (POCT)=2.6   06/14/12: INR (POCT)=2.8   Last influenza vaccine (2011), last pneumococcal vaccine (2003)

A: 1. Type 2 DM uncontrolled with most recent A1c 9.3% (goal < 7%) and elevated SMBG with both elevated fasting and 2-hr PPG values. Adjustment in therapy warranted to bring BG to goal and prevent microvascular and macrovascular complications. Unable to further increase oral therapy and basal insulin will not address post-prandial glucose excursions. Addition of mealtime insulin therapy recommended, use of insulin pens may improve difficulties using vial/syringe. Patient c/o cost of Januvia and addition of this therapy has not achieved treatment goals. Discontinuation warranted. Education on diabetic diet also warranted. Diabetes and CDC guidelines recommend annual influenza vaccination and pneumococcal vaccination as indicated, pt is in need of updated influenza vaccination and it has been > 5 yrs since pneumococcal delivered (also delivered prior to age 65). 2. Subtherapeutic INR of 1.6 with goal of 2 to 3 for an indication of Afib, treatment length indefinite. Holding 2 doses of Coumadin 2/2 bruising at insulin injection sites is likely cause for low INR today. Education on importance of taking Coumadin everyday warranted, no permanent dose change recommended as patient was previously stable on this TWD. 3. Osteoarthritis pain poorly controlled with use of acetaminophen up to 3 grams daily, currently using ibuprofen which can increase risk of bleeding with concurrent warfarin therapy, a change in therapy is recommended to address patient’s pain and improve ADL’s. Consideration of cardiovascular risk (type 2 DM, family history of CVD, smoking, HTN) and GI risk (age >65, on anticoagulants, NSAID use < 1 month) should be weighed in treatment choice. 4. Hyperlipidemia is currently untreated due to patient d/c statin use ~ 6 months ago, LDL above goal (<100 mg/dl) , TG above goal (<150 mg/dl), HDL below goal (>50 mg/dl) and TC above goal (<200 mg/dl). Re-initiation of statin therapy as well as TLC warranted to bring LDL to goal and prevent CVD events. 5. Tobacco use—smoking cessation is encouraged given patient’s history of COPD and increased CVD risk with type 2 DM, HTN, and hyperlipidemia. Patient is unsure of a quit attempt at this time. 6. Poor medication compliance with tiotropium for COPD, patient unaware therapy should be used daily. Also discontinued statin therapy without consulting physician or pharmacist for advice.

P: 1. Type 2 DM—Discontinue Januvia 100 mg daily. Continue Metformin 1000 mg BID w/ meals, Change Lantus 50 units SC QHS to Solostar pen, Begin Humalog/Novolog/Apidra (based on insurance coverage) Pen 5 units SC 15 minutes before each meal. Titrate by 2 units every 3 days until 2-hr PPG at goal (< 180 mg/dl). Check blood glucose 3x daily (fasting and 2 alternating 2-hr PPG). Record on log and bring to next visit. Recheck A1c in November, order urine microalbumin/Cr ratio, deliver influenza and pneumococcal vaccination 2. Subtherapeutic INR—continue warfarin 5 mg daily x 2.5 mg MWF. Recheck INR in 10 days (accept answers b/w 7 and 14 days). 3. Osteoarthritis—discontinue ibuprofen. Advise against use of NSAIDs due to increased risk of bleeding warfarin. Initiate tramadol 50 mg every 6 hours as needed for pain. Recommend low impact exercise such as aquatic aerobics and weight loss. 4. Hyperlipidemia—resume simvastatin 20 mg QHS, recheck lipid panel in 3 months. 5. Tobacco use—cessation strongly encouraged. May initiate nicotine lozenge 2 mg PRN cravings up to 20 lozenges per day x 6 to 12 weeks. Behavioral counseling can be offered along with NRT to improve chance of success. 6. Poor medication compliance—educate on importance of daily use of tiotropium for COPD and importance of consulting a physician/pharmacist before discontinuing medication.

E: 1.DM—educate on use of insulin pens and injection technique to minimize bruising, educate on s/sx of hypoglycemia, importance of controlling DM to prevent complications, and diabetic diet. Consider referral to CDE or nutritionist 2. Subtherapeutic INR—educate on importance of taking Coumadin every day to prevent strokes, advise on what to do with missed doses, and importance of frequent INR monitoring, avoid use of NSAIDs with warfarin due to increased risk of bleeding 3. OA—educate on non-pharmacologic treatments for OA pain (heat/cold therapy, use of assistive devices such as walkers, and weight loss), 4. Hyperlipidemia—educate on risks of diabetes with statins and how the evidence relates to her, reduce intake of saturated fat, cholesterol, trans fat and increase omega-3 fatty acids, fiber, and plant stanol/sterol intake, 5. Tobacco use—educate on options to help her quit, importance of cessation and impact on progression of COPD, 6. Medication compliance—use pill boxes, reminders, and medication calendars to assist you with remembering medications.