CASE STUDY Patient with T2DM and multiple comorbidities
A 49-year-old African American woman, who qualifies for Medicare because of disability, first enrolled in our pharmacy’s advertised diabetes education classes 3 years ago, out of concern over her long history of uncontrolled diabetes. At that time, her body mass index (BMI) was 35 kg/m2 and her A1C was 10%. In addition to T2DM, she had asthma, gastroesophageal reflux disease (GERD), hypertension, hyperlipidemia, gout, seasonal allergies, and a prior myocardial infarction.
I have worked closely with this patient over the succeeding 3 years, providing weekly diabetes education and counseling. At first she was using NPH insulin twice a day and adjusting the doses on her own, without the close involvement of her endocrinologist. As long-acting insulin analogs (ie, insulin glargine and insulin detemir) have relatively flat and more predictable time–action profiles that last up to 24 hours,24 I persuaded her to switch to a basal–bolus regimen with insulin detemir and insulin aspart. Insulin detemir is also associated with less weight gain and fewer hypoglycemic episodes than NPH insulin,25-27 which was especially important given this patient’s obesity and fear of hypoglycemia. It is, however, important to note that changes in medication should also be reviewed with the patient’s treating physician. In addition, I spent a year working closely with the patient on carbohydrate counting.
Pharmacists can also explore different insulin delivery methods with patients. Many patients find insulin pens more convenient, more discreet, and easier to use than a vial and syringe.28,29 Insulin pumps can also be a useful option for certain patients.30 Recently, this patient began using an insulin pump, which was recommended to help her achieve better blood glucose control, despite her erratic meal patterns. The results are generally good, although she still has glucose spikes due to metabolic issues and inconsistent eating patterns, and her BMI has increased slightly (36.1 kg/m2). However, her current A1C is 7.1%.
This patient’s complicated medical history and large number of medications (TABLE 3) suggested the need for a comprehensive medication review, as described in the Core Elements of MTM.18 The result of the review was a letter to her physician, with a number of recommendations about her medications, lifestyle changes, and symptoms to investigate. Among the problems discovered were muscle pain and creatine kinase elevation as a possible side effect of her statin therapy; poorly controlled hypertension; poor compliance with some of her medications; the possibility of an interaction between her insulin and beta-blocker; symptoms of congestive heart failure; and signs of possible Cushing’s syndrome. Among the recommended actions were withdrawal of the statin until muscle symptoms could be investigated and modifications of some of her medications to a more easily tolerated form or dosage schedule. Diet, exercise, and weight loss were recommended to ameliorate many of her health problems. Her physician was also advised that she should avoid foods that would exacerbate her GERD and gout and that she should follow the low-salt DASH (Dietary Approaches to Stop Hypertension) diet to help manage her hypertension. It is important to note that, while the pharmacist may make recommendations for symptoms to be investigated, it is the physician who should be making the diagnosis, and pharmacists and physicians should be collaborating as part of a treatment team.
This patient’s fear of hypoglycemia has presented an ongoing challenge in her diabetes education. She often would load up on carbohydrates before leaving work to avoid becoming hypoglycemic on the train ride home. She is extremely insulin resistant, and it has required a major effort to help her feel comfortable with taking enough insulin. She has been very conscientious in documenting the results of her glucose self-monitoring, but has received little education from her physician about what to do with the information. Carbohydrate counting has been difficult for her and continues to be a major focus of our weekly sessions.
The close attention that this patient receives from her pharmacist contrasts with the usual care received by many patients with diabetes. It is not uncommon for patients to tell me that, when they were first diagnosed with T2DM, they were given a prescription and, at best, sent to a dietitian for nutritional counseling. Newly diagnosed patients are advised to monitor their blood glucose; because I see patients once a week, it is easy to help them understand the immediate interactions between diet, exercise, insulin sensitivity, specific medications and doses, and glucose levels.
The medication-related action plan (MAP), one of the Core Elements of MTM,18 is a useful tool to help patients take control of their progress in managing their diabetes. We use it as a medical action plan, involving far more than just medications. These plans are completed at every visit, collaboratively with the patient, and reviewed as follow-up at the next visit. The form contains a space for each planned activity and a space to document progress toward that activity or its completion. Activities might include changing the time of day a medication is taken, going for a lab test, asking the physician to explain cholesterol levels, or observing the emotional states that might lead to binge eating. Holding patients accountable for the activities in the MAP helps them to achieve their self-management goals.