A primary provider approaches you to figure out why one of his patient’s diabetes is out of control. Nothing seems to work. The case:
A 59 year old female has a past medical history of:
- COPD
- Type 2 Diabetes
- Hypertension
- GERD
- Chronic back pain
A1C= 10.2
Current meds include:
- Lantus 30 units hs
- Victoza 0.6 mg daily
- Advair 100/50 twice daily
- Spiriva daily
- Bystolic 10 mg daily
- Ramipril 5 mg daily
- Aspirin 325 mg daily
- Lidoderm patch as needed for back pain
- Acetaminophen as needed
- Combivent as needed
- My initial thought = $$$$$$$$$$$$$$! Can this patient afford all the medications she is supposed to be taking. This patient is on a ton of medications that are really expensive which could potentially be leading to a compliance problem. I would assess the Bystolic and see if an easy switch to a different beta-blocker would be appropriate to save $. (Always remember to look at the allergy list when recommending a switch or switching meds!!!) I would also assess Lidoderm use/need. If the patient’s respiratory symptoms are under control it would be interesting to see if we could cut out the low dose Advair. Looking at Combivent use would help us assess this as well as inquiring about respiratory symptoms.
- If $$/adherence to medications is not an issue, we certainly have room to go up on the Victoza to get a better handle on the patient’s diabetes. Accuchecks would be nice to know to help guide our therapy and assess if she gets really high at certain times of the day.
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I think, we can add metformin to her drug list ,start with 500 mg a daily , that is after discussing her diet style pattern and see if she has a chart for her blood sugar level.
It is import to collect information on life style for patient suffering from hypertension and /or diabetes.
His drug list, his weight , life style , diary of BP measurement and Blood sugar level .
I would look at switching Lantus to Humulin R or Humalog tid 15 to 30 minutes before meals. Lantus is a large molecule and sometimes patients cannot absorb it subcutaneously to help bring the glucose down.
I would add a generic Statin, change Bystolic to a generic Beta-Blocker and also add Pepcid or Zantac for Gerd (if not controlled may be a PPI)
Assume this pt is obese??? Weight loss! Cure the DM2 with ideal body weight so will be able to get off lantus and victoza and see how far we can cut antihypertensives with weight loss as well.
Losing weight helps with a lot of things, but like with smoking, it’s not that easy for a patient to change their lifestyle. Also, the answer is not always weight. I’ve seen a lot of normal weight patients with T2DM or HTN.
I would want to ask though why the patient is not on metformin (did she d/c for side effects, etc) and see if that’s an option to revisit.