Presented by:Vineetha Menon

VI pharm DJSSCP

RISK FACTORS:•Diet and obesity, increasing age, female gender, and genetics.•Reduced sleep- effect on metabolism•Medical conditions and drugs

DIAGNOSIS:•Fasting plasma glucose •OGTT

SYMPTOMS:•Numbness and tingling of extremities•Diarrhea•Erectile dysfunction•Urinary incontinence•Facial, mouth and eyelid drooping•Vision changes•Difficulty swallowing•Speech impairment

SYMPTOMS:Anxiety, confusion, reduced alertness, headache, blurred vision, weakness and numbness of limbs, nausea, vomiting

DIAGNOSISPersistently high blood pressure- 3 separate readings at 1 month interval

RISK FACTORS:•Obesity•Genetics•Diabetes•High cholestrol•Low birth weight•Smoking

IP NO : 1310280 UNIT : VKH general medicine

AGE : 38 yrs SEX : Female

WEIGHT: 52 kg DOA : 27/8/13

DOD : 31/8/13

Patient details

C/O: Giddiness and generalized weakness 1week Burning and Tingling sensation of lower limbs Blurring of Vision

H/O: Burning micturition

Reason for admission

SHx : NS

PMHx : K/C/O Type II DM x 3yrs (on T. triglycomet) and

HTN x 1yr (T. Amlodipine 2.5mg)

Allergies : NKA

Type II DM with Hypertension

? Peripheral neuropathy

? UTI

Provisional diagnosis

Day 1

c/o: Burning sensation in lower limbs

BP : 140/100 mmHg PR : 80 bpm

ADV : Hb, TC, DC, RBS, HbA1C, Urine routine, Lipid Profile, AST, ALT, SCr, ECG, Ophtho Opinion CST

8 pm CBG : 196 mg/dl

Medication Dose Route Frequency D1 D2 D3 D4 D5

Glibenclamide+ metformin+ pioglitazone

5mg+ 500mg+1

5mg

PO 1-0-1 +

Pantoprazole 40 mg IV 1-0-0 + (tab)+

+ + +

Amlodipine 2.5 mg PO 1-0-1 +

Losartan 50 mg PO 1-0-1 + + + +

H. mixtard 30/70 SC 20-0-10 + 22-0-12

+ +

Pregabalin+ Mecobalamin

75mg+750µg

PO 1-0-1 + + + +

Ciprofloxacin 100 ml IV 1-0-1 + + + +

Metformin 500 mg PO 1-0-1 + +

Medications:

Day 2

BP : 130/98 mmHg PULSE : 84 bpm

C/o: Tingling and numbness of lower limbs Adv: Fundoscopy, Diet Counselling and Urine culture

STOP: T. Triglycomet

START: Inj. H.Mixtard (30/70) S/C 20-0-10

C. Pregabalin+ Mecobalamin (75mg+750mcg) PO 1-0-1

Inj. Ciprofloxacin 100 ml IV 1-0-1

6 am CBG : 273 mg/dl1 pm CBG : 176 mg/dl8 pm CBG : 210 mg/dl

Day 2 cont…..

Hematology:

Hb 12 mg/dl

TLC 5400 cells/cu.mm

DLC: N 60%

L 35%

M 01%

E 04%

B 00%

PLT 1.8 cells/cu.mm

ESR 30 mm/hr

Biochemistry:

HbA1c 8

Urea 20 mg/dl

Se. Cr 1.2 mg/dl

AST 23 U/l

ALT 19 U/l

Day 2 cont…..

Cholesterol 232 mg/dl

HDL 39 mg/dl

LDL 78 mg/dl

VLDL 15 mg/dl

TG 80 mg/dl

Sodium 138 mmol/l

Potassium 4.0 mmol/l

Chloride 105 mmol/l

Albumin +

Sugar ++

Pus cells 6-8

Epithelial cells 2-3

Presence of occasional casts

ECG WNL

Medication Dose Route Frequency D1 D2 D3 D4 D5

Glibenclamide+ metformin+ pioglitazone

5mg+ 500mg+1

5mg

PO 1-0-1 +

Pantoprazole 40 mg IV 1-0-0 + (tab)+

+ + +

Amlodipine 2.5 mg PO 1-0-1 +

Losartan 50 mg PO 1-0-1 + + + +

H. mixtard 30/70 SC 20-0-10 + 22-0-12

+ +

Pregabalin+ Mecobalamin

75mg+750µg

PO 1-0-1 + + + +

Ciprofloxacin 100 ml IV 1-0-1 + + + +

Metformin 500 mg PO 1-0-1 + +

Medications:

O/e : Burning sensation decreased.

Optho opinion : Rt eye: Normal Fundus

Lt eye: Fundus- Superficial Hemorrhage, microaneurysm, retinal retinopathy with Grade –III HTN

Adv: INJ. H.Mixtard (30/70) S/C 22 -0- 12

CST

Day 3

BP:120/80 mmHg PULSE: 80 bpm

6 am CBG : 210 mg/dl1 pm CBG : 138 mg/dl8 pm CBG : 179 mg/dl

Urine Culture report : no bacterial growth after 24 hrs of incubation

Medication Dose Route Frequency D1 D2 D3 D4 D5

Glibenclamide+ metformin+ pioglitazone

5mg+ 500mg+1

5mg

PO 1-0-1 +

Pantoprazole 40 mg IV 1-0-0 + (tab)+

+ + +

Amlodipine 2.5 mg PO 1-0-1 +

Losartan 50 mg PO 1-0-1 + + + +

H. mixtard 30/70 SC 20-0-10 + 22-0-12

+ +

Pregabalin+ Mecobalamin

75mg+750µg

PO 1-0-1 + + + +

Ciprofloxacin 100 ml IV 1-0-1 + + + +

Metformin 500 mg PO 1-0-1 + +

Medications:

C/O: Generalized Weakness

Adv : START: T. Metformin 500 mg PO 1-0-1

CST

Day 4

BP: 110/80 mmHg PR: 80 bpm

6 am CBG : 186 mg/dl1 pm CBG : 110 mg/dl8 pm CBG : 132 mg/dl

Medication Dose Route Frequency D1 D2 D3 D4 D5

Glibenclamide+ metformin+ pioglitazone

5mg+ 500mg+1

5mg

PO 1-0-1 +

Pantoprazole 40 mg IV 1-0-0 + (tab)+

+ + +

Amlodipine 2.5 mg PO 1-0-1 +

Losartan 50 mg PO 1-0-1 + + + +

H. Mixtard 30/70 SC 20-0-10 + 22-0-12

+ +

Pregabalin+ Mecobalamin

75mg+750µg

PO 1-0-1 + + + +

Ciprofloxacin 100 ml IV 1-0-1 + + + +

Metformin 500 mg PO 1-0-1 + +

Medications:

C/O: No fresh complaints

Adv : Discharge

Review after 1 week

Day 5

BP: 120/80 mmHg PR: 80 bpm

6 am CBG : 110 mg/dl

Medication Dose Route Frequency D1 D2 D3 D4 D5

Glibenclamide+ metformin+ pioglitazone

5mg+ 500mg+1

5mg

PO 1-0-1 +

Pantoprazole 40 mg IV 1-0-0 + (tab)+

+ + +

Amlodipine 2.5 mg PO 1-0-1 +

Losartan 50 mg PO 1-0-1 + + + +

H. mixtard 30/70 SC 20-0-10 + 22-0-12

+ +

Pregabalin+ Mecobalamin

75mg+750µg

PO 1-0-1 + + + +

Ciprofloxacin 100 ml IV 1-0-1 + + + +

Metformin 500 mg PO 1-0-1 + +

Medications:

Discharge medications

Review after 1 week

Medications Dose Route Frequency

H. mixtard 30/70 SC 22-0-12

Losartan 50 mg PO 1-0-1

Pregabalin+ Mecobalamin

75mg+750mcg

PO 1-0-1

Metformin 500 mg PO 1-0-1

Pantoprazole 40 mg PO 1-0-0

Pharmaceutical Care Plan

Subjective evidences:

Giddiness & Generalized weakness Burning and Tingling sensation of

lower limbs Blurring of Vision

Objective evidences:

Elevated BP Elevated blood sugar levels

(CGB and HbA1c)

Type II DM with Peripheral Neuropathy with Hypertension

Assessment

HYPERTENSION:To relieve signs and symptomsTo control the elevated BP and maintain it in the near normal levelsTo reduce further complicationsTo improve the quality of life by counselling the patient about his disease and managament of HTN.

DIABETES MELLITUS:To relieve signs and symptoms To maintain a near normal blood glucose levelsTo reduce further progression of micro vascular and macro vascular complications To prevent symptoms of hyperglycemia and hypoglycemiaTo improve the quality of life by counselling the patient about his disease and managament of Diabetes.

Goals of treatment

PERIPHERAL NEUROPATHY:To attain relief from pain and to restore functionTo control the underlying disease condition causing itPreventing significant decrease in the patients QOL

BP was under control by day 2 Burning sensation decreased by day 3 Diabetes was under control by day 5

Goals achieved

HYPERTENSION: ACE inhibitors/ABR Thiazide diuretics

TYPE II DIABETES MELLITUS: Insulin Biguanides (statins)

DIABETIC NEUROPATHY: Tricyclic antidepressants Serotonin norepinephrine reuptake inhibitors Antiepileptic drugs Opioid analgesics

Treatment options

Inadequate dose: Pregabalin Untreated indication: Hyperlipidaemia

Problem identified

Monitoring Parameters For

disease

BP ECG CXR Lipid profile Metabolic panel Renal function test Fundoscopy CBG HbA1c

Monitoring parameters for drugs

ADRs

Monitoring Parameters

Patient Counselling

RISK FACTORS:•Diet and obesity, increasing age, female gender, and genetics.•Reduced sleep- effect on metabolism•Medical conditions and drugs

SYMPTOMS:Anxiety, confusion, reduced alertness, headache, blurred vision, weakness and numbness of limbs, nausea, vomiting

RISK FACTORS:•Diet and obesity, increasing age, female gender, and genetics.•Reduced sleep- effect on metabolism•Medical conditions and drugs

SYMPTOMS:•Numbness and tingling of extremities•Diarrhea•Erectile dysfunction•Urinary incontinence•Facial, mouth and eyelid drooping•Vision changes•Difficulty swallowing•Speech impairment

About the medication:

- Medication adherence - How and when to take medications - Missed dose

Restricted •Salt and sugar intake•Red meat•Dairy products

Avoid stress

THANK YOU