DD Final Case Presentation Presented By Steven Fiedler

DD Final Case Presentation Presented By: Steven Fiedler Pharm. D. Candidate 2015

DD �CC: “I am frustrated, every food I like makes me sick” �HPI: Last A 1 c was 8. 6% in September 2014. Enrolled in Diabetes Insulin Treat to Target Clinic in October 2014. Upon enrollment, re-started Metformin and Glipizide. When asked about A 1 c, patient stated, “They took me off all my meds, the last time I relapsed they took me off my diabetes medications”.

DD PMH �GERD 10/2006 �Obesity 10/2006 �HL 04/2007 �T 2 DM 08/2008 �Insomnia 07/2009 �Impotence 12/09 �PTSD 10/10 �Alcohol dependence 12/11 �Opioid use with alcohol dependence 11/12 �Leiomyoma 01/13 �DVT 12/13 �HTN 11/14 �Hematuria 11/14 �Hypercalcemia 11/14 �Degenerative arthritis of Lt Knee 11/14 �Bipolar mania 12/14

DD �FH- To be added �SH – recovering alcoholic, last relapse was 2 weeks ago. Sister is his support system although she may be abusing him financially and emotionally. Lives at Soldier On , on the hill adjacent to VA.

DD Medications �Metformin 1000 mg; po; BID �Glipizide 5 mg; po; BID; WM �Simvastatin 40 mg; po; HS �Metoprolol tartrate 100 mg; po; BID �Topiramate 50 mg; po; HS �Trazodone 100 mg; po; HS �Aspirin EC 81 mg; po; daily �MVI 1 tablet; po; daily �Glucose 4 gm Chew 3 tabs; po; PRN; hypoglyc emia �Clotrimazole AAA; topically; BID �Acetaminophen 325 mg 2 tabs; po; q 6; PRN; pain �Ranitidine 150 mg; po; BID; PRN; GE RD

DD �Allergies – �ROS – The patient reports in overall good affect, no confusion, trauma, shakiness, or any other neurologic symptoms. Patient doesn’t really know why he is here, just that he knows his A 1 c isn’t reflective of a true average and that 3 months on his meds and a more motivated diet will get him towards his goals.

DD PE �Gen – Obese veteran appearing stated age NAD �VS �HEENT – PERRLA, EOMI �Neck/Lymph- supple no LAD �Lungs – CTA

DD PE �CV – RRR no MRG �ABD – Q 4 tenderness, guarding �Genit/Rect – deferred �MS/Ext – No CC LLE on Rt leg, currently treated with clotrimazole �Neuro – A&O x 3; CN 2 -12 intact

DD Labs (Date)

DD Exams

DD Problem List �T 2 DM �Alcohol Dependence �β-Blocker Withdrawal

Type 2 Diabetes Mellitus (T 2 DM) Problem #1

DD �Managed on Metformin and Glipizide and lifestyle modifications �When his medication and regimen is working, his A 1 c is 6 -6. 9 �Upon last intake for alcohol intoxication, they discontinued his regimen �Last A 1 c in September was 8. 7%

Diabetes Not This

Risk Factors for Diabetes �Age ≥ 45 years �First-degree relative with diabetes �Overweight with central obesity (BMI ≥ 25 kg/m 2) �Hypertension (BP ≥ 140/90 mm Hg ) �Treated for hypertension �HDL cholesterol <35 mg/d. L �Triglyceride level >250 mg/d. L American Diabetes Association. Standards of medical care in diabetes— 2015. Diabetes Care 2015; 30(Suppl 1): S 4–S 41.

Signs and Symptoms T 2 DM �Polyuria �Polydipsia �Blurry vision American Diabetes Association. Standards of medical care in diabetes— 2015. Diabetes Care 2015; 30(Suppl 1): S 4–S 41.

Diagnosis of T 2 DM �A 1 c �≥ 6. 5% �Fasting Plasma Glucose �≥ 126 mg/d. L � 2 hour plasma glucos during an OGTT �≥ 200 mg/d. L �Random Plasma Glucose (w/ classic symptoms) or Hyperglycemic crisis �≥ 200 mg/d. L �In the absence of classic cymptoms, testing should be repeated to confirm diagnosis American Diabetes Association. Standards of medical care in diabetes— 2015. Diabetes Care 2015; 30(Suppl 1): S 4–S 41.

Treatment Algorithm for Management of T 2 DM Nathan DM, Buse JB, Davidson MB, et al. Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes Care 2009; 32: 193 -203.

Alcohol Dependence (AD) Problem #2

DD � 12/11 – Diagnosed with Alcohol Dependence �LOOK UP IN CPRS

Signs and Symptoms of AD and Withdrawal �Seizure �Unresponsiveness �Confusion �Sweating �Tremor �Shaking �Tachycardia �Deep tendon reflexes Mayo-Smith MF. Pharmacological management of alcohol withdrawal: a metaanalysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997; 278: 144– 151.

Lab abnormalities in AD �↑ LFTs, including ↑ AST/ALT ratio �↑ INR (in the absence of warfarin use) �↓ albumin �↓ Potassium (K+) �↓ Magnesium (Mg+) Mayo-Smith MF. Pharmacological management of alcohol withdrawal: a metaanalysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997; 278: 144– 151.

DD �DD has come into some money and the temptation to leave Soldier On and rent a hotel room for the weekend is too much. He goes downtown and frequents the local watering hole and then returns to his hotel room and goes to the mini-fridge. �Once he runs out of money he reluctantly returns to Soldier On and is admitted to urgent care for acute alcohol withdrawal.

Goals of therapy �Control acute symptoms of alcohol withdrawal. �Prevent progression to delirium tremens and withdrawal seizures �Correct electrolyte imbalances �Start prophylaxis to prevent Wernicke’s encephalopathy. �Enroll patient in a program to help him stop drinking—followed by long-term abstinence control. �Work up potential liver disease—prevent further progression. Mayo-Smith MF. patient Pharmacological management of alcohol withdrawal: with a meta-analysis � Refer to dietitian for assistance longand evidence-based practice guideline. American Society of Addiction Medicine Working nutritional stability Groupterm on Pharmacological Management of Alcohol Withdrawal. JAMA 1997; 278: 144– 151.

Wernicke’s Encephalopathy

Treatment �Algorithms are set dosing frequency based on the CIWA-Ar Score. �The higher the score the greater the loading dose for the Benzodiazepine and then taper gradually. �Each hospital follows its own protocol based on symptoms

AD treatment �Mostly supportive care once the withdrawal is managed. �Fluids: NS or ½ NS if Sodium is elevated �Electrolytes: Banana bag (K+, Mg+) �Nutrition and Supplements: Thiamine, B 12, MVI

Beta Blocker Withdrawal Problem #3

DD’s presentation �Ran out of Metoprolol Tartrate 100 mg �Has been on the medication for years �Stopped taking the medication on Monday due to low supply �Didn’t take next dose until Wednesday morning

Signs and symptoms �Sweating �Tumultuous stomach �Racing heart beat �Heart beating out of the chest Lefkowitz RJ, Caron MG, Stiles GL. Mechanisms of membrane-receptor regulation. Biochemical, physiological, and clinical insights derived from studies of the adrenergic receptors. N Engl J Med 1984; 310: 1570.

Stopping B-Blockers Abruptly Can Lead to… �Rapid asymptomatic return of BP to pretreatment levels �Slow asymptomatic return of pretreatment levels �Rebound BP with signs and symptoms of sympathetic overactivity �Overshoot of BP above pretreatment levels Houston MC. Abrupt cessation of treatment in hypertension: consideration of clinical features, mechanisms, prevention and management of the discontinuation syndrome. Am Heart J 1981; 102: 415.

Pharmocokinetics of B-blockers Drug A D M Atenolol 50% Bioavailabilit y 6 -16% protein binding Hepatic R: 50% F: 50% Bisoprolol 80% Bioavailabilit y 30% protein Hepatic R: 50% binding 9 -12 h Carvedilol 25 -35% Bioavailabilit y Systemic (Vd 115 L) Hepatic S: F/B 2 D 6 7 -10 h 10% albumin bound Hepatic R: 95% 2 D 6 3 -4 h Metoprolol 50% Bioavailabilit y E T½ 6 -7 h Propranol 30 -70% 93% protein Hepatic R: <1% IR: 3 -6 h Vd: Volume of Distribution; R: Renally Eliminated; F: Fecally ol Bioavailabilit binding ER: 8 Eliminated; S: Systemically Eliminated; F/B: Fecally/ biliary; UC: y 20 h Unchanged Atenolol, Bisoprolol et. al. In: DRUGDEX Evaluations [database on the Sotalol 90 -100% No protein Hepatic R: 6612 h Internet]. Greenwood Village (CO): Thompson Micromedex; 1974 -2012 [cited 15 Bioavailabilit binding 88% Aug 2012]. .

β-Blocker Withdrawal �β-blockers bind to beta- adrenergic receptors of the post synaptic cell �Withdrawal thought to reflect a rapid return of Epinephrine and Norepinephrine that has been suppressed during therapy �This leads to unopposed peripheral α-receptormediated vasoconstriction Houston MC. Abrupt cessation of treatment in hypertension: consideration of clinical features, mechanisms, prevention and management of the discontinuation syndrome. Am Heart J 1981; 102: 415.

Mechanism

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