Type 2 Diabetes Mellitus - quality prescribing strategy: improvement guide 2024 to 2027

13. Case studies

The following case studies illustrate different aspects of reviewing management of people with T2DM

Case study 1: Remission of Type 2 Diabetes

Case summary

Background (age, sex, occupation, baseline function)

• 57 years old
• Male
• Self-employed taxi driver

History of presentation/ reason for review

• Referral to Weight Management Service from GP.
• Reports that “drank and ate too much in his 20’s” but active in his job. Since becoming a taxi driver and quitting smoking his weight increased. Works 12-hour shifts five to six days a week, leaving little time for physical activity.
• Tried commercial slimming clubs in the past but regained weight once stopped attending.
• Reports overeating in response to stress.
• Does no cooking at home – meals are mostly on the go, grabbing convenience foods whilst driving.

Current medical history and relevant comorbidities

• T2DM diagnosed 3 years ago
• Essential hypertension
• Gastro-oesophageal reflux disease (GORD)
• Depressive disorder
• Family history of CVD and T2DM with a family member requiring an amputation due to peripheral vascular disease
• High stress levels during the COVID-19 pandemic and lack of income

Current medication and drug allergies (include OTC preparation and herbal remedies)

• Candesartan 8mg tablets - one tablet daily
• Metformin 500mg tablets - two tablets twice daily
• Sildenafil 100mg tablets - one tablet daily as required
• Trazadone 50mg capsules - one capsule at night

Lifestyle and current Function (inc. frailty score for >65yrs) alcohol/ smoking/ diet/ physical activity

• Alcohol – social drinker
• Ex-smoker
• Physical activity level low – struggles to walk any distance without pain

“What matters to me” (patient ideas, concerns and expectations of treatment)

• His aims are to put his Type 2 Diabetes into remission, stop his medications and improve his mobility and quality of life.

Results e.g. biochemistry, other relevant investigations or monitoring

• Height 1.85m
• Weight 148.6 kg
• BMI 43.4 kg/m²
• HbA1c 67mmol/mol.
• Blood pressure normal range on antihypertensive medication
• LDL cholesterol 3.3 mmol/L

Most recent relevant consultations

• Attended a few appointments with team psychologist prior to starting the intervention. Discussed concerns around eating behaviours including boredom / comfort eating and high stress levels.
• Placed on the NHS Scotland/Counterweight Plus Remission Programme - total diet replacement (TDR) – 800 calorie per day soups and shakes diet (4/day) for an initial 12 weeks. Fortnightly appointments with the specialist dietitian for treatment through the program.
• Metformin and candesartan stopped on day 1 of the intervention as per the agreed medical management protocol.
• 31kg weight lost at the end of 12 weeks of TDR – blood glucose, weight and blood pressure checked every 2 weeks at appointments with the dietitian.
• After 12 weeks of TDR, food was slowly reintroduced
• A further 13kg was lost over the 12 weeks on the food reintroduction stage
• BP medications were reintroduced due to a rebound increase in resting BP, at half the dosage at the start of the intervention.
• At 6 months:
• Appointments monthly
• Weight loss was 29% of body weight, 10 inches lost from waist
• Metformin stopped, BP medication dosage halved.
• Patient was jogging multiple times per week – 5km distances
• HbA1c had reduced from 65 to 46 mmol/mol – now in remission.
• Progressing with second year of weight loss maintenance in the type 2 diabetes remission program, including monthly appointments with dietitian.
• Maintaining lifestyle changes and continuing to regularly monitor measurements
  • Wife attended a cooking class and supports with planning and cooking meals
  • Takes meals with him in his taxi instead of buying food on the go, also helps with cooking evening meal
  • Has progressed from being unable to walk round block to regularly running 5km distances.
• Current medications:
• Candesartan 4 mg OD
• Trazadone 50 mg
• Current measurements:
• Weight: 99.9 kg
• ^· BMI: 29.2 kg/m²
• Total weight loss: 32.7%
• HbA1c 36 mmol/mol
• Cholesterol: 2.7 mmol/l
• Remains in remission

Step 1.

Aims

What matters to the individual about their condition(s)?

Process:

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice

Person specific issues to address:

• Reduce medication
• Keep diabetes in remission

Step 2.

Need

Identify essential drug therapy

Process:

Identify essential drugs (not to be stopped without specialist advice*)

• Drugs that have essential replacement functions
• Drugs to prevent rapid symptomatic decline

* with advice from healthcare professional with specialist interest

Person specific issues to address:

• Continue on candesartan. BP has improved with weight loss, but not enough to stop

Step 3.

Does the individual take unnecessary drug therapy?

Process:

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address:

• No, but candesartan and metformin to be stopped during TDR.

Step 4.

Effectiveness

Are therapeutic objectives being achieved?

Process:

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address:

• None required. BP within target range.

Step 5.

Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process:

Identify individual safety risks by checking for

• appropriate individual targets
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific issues to address:

• Candesartan and metformin should both be temporarily stopped (if these need to be reinstated).

Step 6.

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process:

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience -

Consider the environmental impact of

• inhaler use
• single use plastics
• medicines waste
• water pollution

Person specific issues to address:

• None - prescribing in keeping with current formulary recommendations
• Patient advised to dispose of medicines through community pharmacy
• Advised patient to only order what is needed, do not stockpile medicines 

Step 7.

Person-centredness

Is the person willing and able to take drug therapy as intended?

Process:

Does the person understand the outcomes of the review?

• Consider teach-back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Person specific issues to address:

• If HbA1c increases consider review and introduce diabetic medications.

Key concepts in this case

• Lifestyle and dietary changes enabled remission of diabetes and stopping medication.
• Mood, self-confidence, self-esteem and relationships have all improved through a combination of more physical activity and mobility, remission of long-term condition and reduction in medications/doctors’ appointments.

Case study 2: Multimorbidity, polypharmacy and symptomatic diabetes

Case summary

Background (age, sex, occupation, baseline function)

• 85-year-old
• Male

History of presentation/ reason for review

• Rising HbA1c and reporting osmotic symptoms

Current medical history and relevant comorbidities

• Type 2 diabetes mellitus – 18 years ago
• Ischaemic heart disease – 11 years ago
• Hypertension – 17 years ago
• Bilateral diabetic retinopathy – 6 years ago
• Chronic Kidney Disease Stage 3 – 5 years ago
• Autoimmune gastritis – 5 years ago
• Macrocytic anaemia – 5 years ago
• Pernicious anaemia – 5 years ago
• Albuminurea – 2 years ago

Current Medication and drug allergies (include OTC preparation and Herbal remedies)

• Aspirin dispersible 75mg tablets - one tablet daily
• Bisoprolol 2.5mg tablets - one tablet daily
• Ferrous fumarate 322mg tablets - one tablet twice daily
• Folic acid 5mg tablets - one tablet daily
• Gliclazide 80 mg tablets - two tablets twice daily
• GlucoRx Nexus test strips - use as directed
• Glyceryl trinitrate 400mcg sublingual spray - use when required
• Hydroxocobalamin 1mg IM injection - once every 3 months
• Linagliptin 5mg tablets - one tablet daily
• Losartan 50mg tablets - one tablet daily
• Metformin 500mg tablets - two tablets twice daily
• Omeprazole 20mg capsules - one capsule daily
• Simvastatin 40mg tablets - one tablet night

Drug Allergies:

• SGLT-2i previously not tolerated due to recurrent balanitis

Lifestyle and current function (inc. frailty score for >65yrs) alcohol/ smoking/ diet/ physical activity

• Rockwood score 4 (vulnerable)
• Lives alone, daughter visits daily
• Wife died in 2021 (dementia) - he was her main carer
• Continues to drive (short distances)
• Eating more than normal and has put on weight
• Attends diabetic retinopathy screening
• Attends podiatrist regularly

“What matters to me” (patient ideas, concerns and expectations of treatment)

• Wishes he didn’t need to take so many medications but organises and fills a compliance aid himself
• Often forgets to take his dose of statin at night
• Struggles to check blood glucose so doesn’t undertake home blood glucose monitoring, however test strips on repeat and issued regularly
• Tired and not going out much – feels “a bit lost since his wife died”

Results e.g. biochemistry, other relevant investigations or monitoring

• Creatinine 127 micromol/L and eGFR = 47 ml/min
• Weight 117kg; height 182cm; BMI 35.32
• Calculated creatinine clearance 49 ml/min (IBW 77kg)
• Urine albumin 18mg/ml, urine creatinine 2.5 mmol/l, ACR 7.2mg/mmol
• No urinary protein detected
• Recent LFTs normal, FBC stable (Hb 123 g/l), folate > 20ug/l
• Last 3 blood pressures 130/63mmHg, 118/62mmHg, 128/62mmHg
• Serum cholesterol 3.9mmol/l, ratio 3.5, triglycerides 3.0 mmol/l
• Hba1c 97mmol/mol (3 months previously was 75mmol/mol)

Most recent relevant consultations

• HbA1c was 75mmol/mol 3 months ago and gliclazide was increased. New blood glucose monitor and test strips were issued.
• Recent leg wound/ulcer - dressed and treated by practice nurse

Step 1.

Aims

What matters to the individual about their condition(s)?

Process:

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice

Person specific issues to address:

• Simplify and reduce medication burden
• Minimise symptoms and improve quality of life, e.g. reduce isolation, and improve mood as feeling “a bit lost”
• Reduce risk of adverse effects from drugs

Step 2.

Need

Identify essential drug therapy

Process:

Identify essential drugs (not to be stopped without specialist advice*)

• Drugs that have essential replacement functions
• Drugs to prevent rapid symptomatic decline

* with advice from healthcare professional with specialist interest

Person specific issues to address:

• Although not considered essential, there is a valid indication for antidiabetic medication: diabetes symptom control

Step 3.

Does the individual take unnecessary drug therapy?

Process:

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address:

• Folic acid 5mg can be stopped as no longer deficient in folate

Step 4.

Effectiveness

Are therapeutic objectives being achieved?

Process:

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address:

• Diabetes poorly controlled despite 3 antidiabetics. Takes linagliptin, which is less effective than other options which also have positive cardiovascular outcomes
• Secondary CVD prevention: likely to derive macrovascular benefit from tight glycaemic control; is on statin and BP within target range

Step 5.

Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process:

Identify individual safety risks by checking for

• appropriate individual targets
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific issues to address:

• Risk of hypoglycaemia due to renal impairment and on sulfonylurea – reduce and stop gliclazide
• Risk of acute kidney injury (losartan, metformin and CKD) especially if acutely unwell. Sick day guidance – check awareness.

Step 6.

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process:

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

• inhaler use
• single use plastics
• medicines waste
• water pollution

Person specific issues to address:

• None - prescribing in keeping with current formulary recommendations
• Patient advised to dispose of medicines through community pharmacy
• Advised patient to only order what is needed, do not stockpile medicines 

Step 7.

Person-centredness

Is the person willing and able to take drug therapy as intended?

Process:

Does the person understand the outcomes of the review?

• Consider teach-back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Person specific issues to address:

• Discuss commencing once weekly injectable therapy with GLP-1RA and stopping linagliptin and also reducing and stopping gliclazide. Daughter happy to help with this as patient would prefer to inject subcutaneously into upper arm. Oral formulation available if preferred.
• Secondary CVD prevention – discussion around importance of weight reduction along with good control of BP, HbA1c and cholesterol. Change to atorvastatin in the morning. Provide support for lifestyle change where appropriate e.g., referral to Weight Management Service.
• Check patient’s understanding of how to best monitor glycaemic control through HbA1c testing and address that there is no need to routinely undertake SBGM. Remove test strips from repeats.
• Encourage attendance at local befriending groups, Men’s Shed, etc to reduce social isolation since his wife died

Key concepts in this case

• Lifestyle management
• Polypharmacy, not limited to treatment of diabetes
• Symptomatic control required.

Case study 3: Diabetes, SGLT-2i* and managing adverse effects

Case summary

Background (age, sex, occupation, baseline function)

• 52 years old
• Female

History of presentation/ reason for review

• Annual diabetic review

Current medical history and relevant comorbidities

• Type 2 diabetes mellitus – 3 years ago
• Established ASCVD
• Essential hypertension - 2 years ago
• Ischaemic heart disease – 2 years ago
• Coronary artery stenting of two vessel disease 2 years ago

Current medication and drug allergies (include OTC preparation and herbal remedies)

• Atorvastatin 40mg tablets – one tablet at night
• Clopidogrel 75mg tablets – one tablet daily
• Lisinopril 20mg tablets – one tablet daily
• Metformin 500mg tablets – one tablet twice daily

Lifestyle and current function (inc. frailty score for >65yrs) alcohol/ smoking/ diet/ physical activity

• Smokes 10 cigarettes per day

“What matters to me” (patient ideas, concerns and expectations of treatment)

“I want to be on the right medicine for my heart”

Results e.g. biochemistry, other relevant investigations or monitoring

• Weight 92kg; height 1.7m; BMI 32.4 kg/m²
• Creatinine 55 micromol/l, eGFR>60
• Urine albumin 3mg/ml, urine creatinine 9.1mmol/l, ACR 0.3mg/mmol
• HbA1c 51mmol/mol
• BP 126/78mmHg

Current issues

• Smoking cessation advice and referral made
• HbA1c above recommended target of 48 mmol/mol
• Would benefit from commencing an SGLT-2i* – both from glycaemic and ASCVD point of view
• Empagliflozin 10mg once daily commenced
• Counselled on side effects
• Medication sick day guidance reiterated and personalised medication list updated via Manage Medicines app/website.
• Four weeks after commencement presents with symptomatic genital thrush
• Clotrimazole ‘combi pack’ prescribed
• Initial improvement in thrush, but after 2 weeks has recurred
• Fluconazole 150mg dose prescribed
• ‘Genital washing’ instructions given
• Option of more prolonged course of fluconazole, if thrush recurs – 150mg every 72 hours for 3 doses, then 150mg once weekly for 6 months

Step 1.

Aims

What matters to the individual about their condition(s)?

Process:

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice

Person specific issues to address:

• Appropriate treatment of cardiovascular disease - “I want to be on the right medicine for my heart”

Step 2.

Need

Identify essential drug therapy

Process:

Identify essential drugs (not to be stopped without specialist advice*)

• Drugs that have essential replacement functions
• Drugs to prevent rapid symptomatic decline

* with advice from healthcare professional with specialist interest

Person specific issues to address:

• Although not considered essential, there is a valid indication for all medication

Step 3.

Does the individual take unnecessary drug therapy?

Process:

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address:

• None are unnecessary

Step 4.

Effectiveness

Are therapeutic objectives being achieved?

Process:

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address:

• HbA1c 51mmol/mol (above recommended target of 48 mmol/mol)
• Existing ASCVD – SGLT-2i* indicated– both from glycaemic and ASCVD point of view

Step 5.

Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process:

Identify individual safety risks by checking for

• appropriate individual targets
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific issues to address:

• Counselled on risks of side-effects:
  • the signs and symptoms of DKA, and advise to seek immediate medical advice if they develop any of these symptoms
  • increased risk of genital infections
  • avoid low carbohydrate diets

Sick Day guidance

• Temporarily stop metformin, lisinopril and empagliflozin

Step 6.

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process:

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

• inhaler use
• single use plastics
• medicines waste
• water pollution

Person specific issues to address:

• None - prescribing in keeping with current formulary recommendations
• Patient advised to dispose of medicines through community pharmacy
• Advised patient to only order what is needed, do not stockpile medicines 

Step 7.

Person-centredness

Is the person willing and able to take drug therapy as intended?

Process:

Does the person understand the outcomes of the review?

• Consider teach-back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Person specific issues to address:

• Smoking cessation advice and referral made
• Empagliflozin 10mg once daily commenced
• Note: 4 weeks after commencement presents with symptomatic genital thrush
• Clotrimazole ‘combi pack’ prescribed
• Initial improvement in thrush, but after 2 weeks has recurred
• Fluconazole 150mg dose prescribed
• ‘Genital washing’ instructions given

Key concepts in this case

• Established ASCVD indicates additional therapy of SGLT-2i, independent of glycaemic control
• SGLT-2i* have known side effect profile
• Requirement to counsel patient accordingly
• Manage side-effects
• Use of simple instructions to minimise side-effects using “genital washing” leaflet (as developed by NHS Lothian, see https://www.lothiansexualhealth.scot/can-this-be-dealt-with-at-a-pharmacy/genital-hygiene/).
• Reiterate sick day guidance and include SGLT-2i

Case study 4: Diabetes, polypharmacy and chronic kidney disease

Case summary

Background (age, sex, occupation, baseline function)

• 59-year-old male, works in family business.
• Lives with wife who does all the cooking.

History of presentation/ reason for review

• Annual diabetes review

Current medical history and relevant comorbidities

• Type 2 diabetes mellitus – 10 years ago
• CKD stage 3B–1 year ago
• Microalbuminuria – 4 years ago

Current medication and drug allergies (include OTC preparation and herbal remedies)

• Atorvastatin 20mg tablets – one tablet daily
• Gliclazide 80mg tablets – one tablet daily
• Metformin 500mg tablets – one tablet twice daily
• Ramipril 10mg capsules – one capsule daily

Lifestyle and current function (inc. frailty score for >65yrs) alcohol/ smoking/ diet/ physical activity

• Non-smoker
• Minimal alcohol
• Diet can be improved
• Plays golf three times weekly

“What matters to me” (patient ideas, concerns and expectations of treatment)

Concerned with reduced kidney function and diabetes control

Results e.g. biochemistry, other relevant investigations or monitoring

• Weight 95kg, BMI 32
• Blood pressure 136/84mmHg
• eGFR 41ml/min
• ACR 10mg/mmol
• LFTs normal
• Serum cholesterol 3.6mmol/l, Triglycerides 1.9 mmol/l
• HbA1c 72mmol/mol
• Foot screen- low risk
• Retinal screen- mild retinopathy

Most recent relevant consultations

Had U&Es checked six months previously. eGFR stable.

Step 1.

Aims

What matters to the individual about their condition(s)?

Process:

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice

Person specific issues to address:

• Patient is concerned about his kidney condition and diabetes control.
• Treatment objectives:
  • Stabilise CKD
  • Improve diabetes control
  • Improve blood pressure

Step 2.

Need

Identify essential drug therapy

Process:

Identify essential drugs (not to be stopped without specialist advice*)

• Drugs that have essential replacement functions
• Drugs to prevent rapid symptomatic decline

* with advice from healthcare professional with specialist interest

Person specific issues to address:

• Although not considered essential, there is a valid indication for all medication

Step 3.

Does the individual take unnecessary drug therapy?

Process:

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address:

• None considered unnecessary

Step 4.

Effectiveness

Are therapeutic objectives being achieved?

Process:

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address:

• To achieve symptom control
  • CKD management: initiate SGLT-2i* to delay the progression of CKD.
• BP control: BP slightly above target.
  • Already on ramipril 10mg daily.
  • Check BP after initiation of SGLT-2i.
• HbA1c is above target and BMI is 32.
  • Check adherence.
  • Add in 3rd line hypoglycaemic agent (GLP-1RA). NB: SGLT-2i don’t exert their glucose-lowering effects in eGFR<45ml/min

Step 5.

Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process:

Identify individual safety risks by checking for

• appropriate individual targets
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific issues to address:

• SGLT-2i:
  • DKA symptoms*; check awareness
  • Raise awareness of thrush/UTI
• GLP-1RA: raise awareness of GI ADRs and symptoms of pancreatitis
• To monitor blood glucose and if below <4.0mmol/l, to stop gliclazide.

Sick Day guidance

• Risk of acute kidney injury (ramipril, metformin and CKD)

Step 6.

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process:

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

• inhaler use
• single use plastics
• medicines waste
• water pollution

Person specific issues to address:

• None - prescribing in keeping with current formulary recommendations
• Patient advised to dispose of medicines through community pharmacy
• Advised patient to only order what is needed, do not stockpile medicines

Step 7.

Person-centredness

Is the person willing and able to take drug therapy as intended?

Process:

Does the person understand the outcomes of the review?

• Consider teach-back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Person specific issues to address:

• Delay progression of CKD:
  • Discuss that the addition of an SGLT-2i* will delay CKD progression and may have beneficial effect on BP control.
  • eGFR to be monitored at least 6 monthly.
  • Follow up patient 1-2 weeks post SGLT-2i initiation to check adherence, ADRs and BP.
• BP control:
  • Discuss if BP still above target after initiation of SGLT-2i, then additional antihypertensive treatment will be added.
• Diabetes management:
  • Once patient is stabilised on the SGLT-2i (1-2 weeks post initiation), initiate GLP-1RA-
  • Check patient understands how to inject GLP-1RA pen correctly and dosing frequency.
  • Follow up patient post initiation at week 1 months 3 and 6. And then every 3-6 months thereafter.
• Non medication intervention: refer patient to a dietician. With patient’s permission, wife is to attend also.

Key concepts in this case

Prescribing for people with comorbidities: CKD

• management of CKD in type 2 diabetes
• tight blood pressure control
• tight glycaemic control

Case study 5: Diabetes and frailty

Case summary

Background (age, sex, occupation, baseline function)

• 65 years old
• Male
• Mild frailty (assessed two months previously) Rockwood 5

History of presentation/ reason for review

• Annual diabetic review

Current medical history and relevant comorbidities

• Transient ischaemic attack (9 and 15 years previously)
• Type 2 diabetes mellitus – 14 years ago
• Essential hypertension - 21 years ago
• Ischaemic heart disease – 31 years ago
• Angina pectoris
• Acute myocardial infarction
• Family history of IHD (noted 14 years ago)

Current medication and drug allergies (include OTC preparation and herbal remedies)

• Alogliptin 25mg tablets – one tablet daily
• Bendroflumethiazide 2.5mg tablets – one tablet daily
• Citalopram 20mg tablets – one tablet daily
• Clopidogrel 75mg tablets – one tablet daily
• Furosemide 20mg tablets – one tablet daily
• Irbesartan 300mg tablets – one tablet daily
• Lercanidipine 10mg tablets – one tablet daily
• Metformin 500mg tablets – one tablet twice daily
• Simvastatin 40mg tablets – one tablet at night

Lifestyle and current function (inc. frailty score for >65yrs) alcohol/ smoking/ diet/ physical activity

• Frailty – mild
• Lives with wife, who does all the housework, preparing meals and shopping
• Mobilises with walking aid
• House on two levels, and requires help with stairs
• Eats a varied diet
• Weight stable
• Attends local optician

“What matters to me” (patient ideas, concerns and expectations of treatment)

• Although pharmacy manages supply of his medication (all on serial prescription) he is reluctant to take medication. “Can I stop any?”
• Often forgets lunchtime dose of metformin.

Results e.g. biochemistry, other relevant investigations or monitoring

• Creatinine 101, eGFR>60
• Weight 84.8kg; height 1.8m; BMI 26.17
• Calculated creatinine clearance 69 ml/min (IBW 75.3kg)
• Urine albumin 3mg/ml, urine creatinine 9.1mmol/l, ACR 0.3mg/mmol
• Recent LFTs, FBC normal
• Last 3 blood pressures: 130/80mmHg, 126/78mmHg, 127/75mmHg
• Serum cholesterol 4.3mmol/l, ratio 3.5
• HbA1c 51mmol/mol

Most recent relevant consultations

• Diabetic monitoring before annual review
• Limited contact with practice due to COVID restrictions
• Received all flu and COVID vaccines

Step 1.

Aims

What matters to the individual about their condition(s)?

Process:

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice

Person specific issues to address:

• Simplify medication – “take less tablets”
• Maintain limited mobility

Step 2.

Need

Identify essential drug therapy

Process:

Identify essential drugs (not to be stopped without specialist advice*)

• Drugs that have essential replacement functions
• Drugs to prevent rapid symptomatic decline

* with advice from healthcare professional with specialist interest

Person specific issues to address:

• None considered essential

Step 3.

Does the individual take unnecessary drug therapy?

Process:

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address:

• Citalopram – started 4 years ago, no indication if ongoing need, although higher incidence of depression in diabetes.
• Furosemide 20mg potentially unnecessary, if lercanidipine is causing swollen ankles

Step 4.

Effectiveness

Are therapeutic objectives being achieved?

Process:

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address:

• BP within target range, occasionally lightheaded but attributed to limited mobility. On triple therapy so review which most appropriate to reduce and stop.
• Diabetes well controlled, mild frailty potentially at risk of hypoglycaemia and complications. However takes alogliptin, which is less effective than other options which have positive cardiovascular outcomes, such as SGLT-2i*.

Step 5.

Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process:

Identify individual safety risks by checking for

• appropriate individual targets
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific issues to address:

• Risk of falls due to anti-diabetic medicines and anti-hypertensives
• Increased risk of acute kidney injury due to combination of diuretics and metformin, especially if acutely unwell.
• Sick day guidance – withhold bendroflumethiazide, furosemide, irbesartan and metformin with dehydrating illness

Step 6.

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process:

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience -

Consider the environmental impact of

• inhaler use
• single use plastics -
• medicines waste
• water pollution

Person specific issues to address:

• None - prescribing in keeping with current formulary recommendations
• Patient advised to dispose of medicines through community pharmacy
• Advised patient to only order what is needed, do not stockpile medicines 

Step 7.

Person-centredness

Is the person willing and able to take drug therapy as intended?

Process:

Does the person understand the outcomes of the review?

• Consider teach-back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Person specific issues to address:

• BP at target and lightheaded – stop lercanidipine as may also be contributing to swollen ankles
• Diabetic control good, often forgets metformin dose at lunchtime. Reduce dose to 500mg twice daily.

Future steps:

• If swollen ankles resolve, stop furosemide.
• Substitute alogliptin for SGLT-2i*, due to ASCVD (and renal) benefits.
• Discuss potential reduction of citalopram, if no symptoms.

Key concepts in this case

• Falls risk
• Mild frailty
• Tight blood pressure control
• Tight diabetic control
• Less suitable medication with comorbidities
• Consider most appropriate anti-diabetic medication
• Duration of treatment course (antidepressant)
• Unnecessary medicine – furosemide