CASE STUDY ANALYSIS: DIABETES
CC: “I’m here for my regular check-up for my diabetes”
HPI: CF is a 70-year-old African American male who is visiting his family practice
physician for follow-up. His blood glucose diary shows he has been monitoring
his glucose levels twice daily (before breakfast and dinner). They range between
135-200mg/dL.
PMH: HTN x 20 years, Type II DM.
FH: Mother (deceased) with DM and HTN; Father (deceased) with CAD, DM, and
HTN; 1 brother (75 yo) who has HTN but otherwise healthy.
SH: No tobacco use (cigarettes) for the last 35 years; alcohol use includes 10-14 beers
per week at the golf course club house but does not play golf or exercise regularly.
All: NKDA.
Meds: Glyburide 5mg QD
EC ASA 325mg QD
Altace 2.5mg QD
PE: Gen- A & O, obese elderly African American male.
Vitals- BP 145/84, P 80, RR 20, T 98.6, Ht. 5’7”, Wt. 102 kg.
Heart- nl S1 and S2, no S3 or S4.
HEENT- PERRLA, EOMI, fundi benign, no retinopathy seen.
Neck- no bruits, mild JVD, no thyromegaly.
Lungs- Clear
Abd- +BS, no masses or bruits.
MS/Ext- nl ROM, muscle strength 5/5 in UE and LE, no peripheral edema.
Neuro- all cranial nerves intact
Labs: Na 141 mEq/L
K 4.0 mEq/L
Cl 106 mEq/L
CO2 22 mEq/L
BUN 20 mg/dL
Ser 1.0mg/dL
Glu 290mg/dL
Hgb A1c 8.6%
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CASE STUDY ANALYSIS: DIABETES
I. AP note
A. Present the problem
CF, a 70 YO African American male, presents today to his PCP for follow-ups on
his glucose readings. He had no other complaints today. He monitors his blood
sugars twice daily (morning and night) and they range between 135-200mg/dL.
B. Risk Factors
oAge
oAfrican American
oFamily History: Mother- DM & HTN; Father- CAD, DM, HTN; Brother- HTN
oComorbidities: HTN x 20 years
oObesity: BMI 35.2
oUnhealthy diet
oPhysical inactivity and sedentary lifestyle
oHistory of cigarette use- quit 35 years ago
oAlcohol consumption (10-14 beers/week)
C. Assessment
1. Evaluation:
CF is a 70-year-old African American male who presented to his PCP for
follow-up on his Type II DM. He routinely checks his blood glucose (BG) levels
twice a day (morning and night) and keeps a BG daily log. His log shows his BG
levels range between 135-200mg/dL. According to labs, his BG today is
290mg/dL and his Hgb A1c is 8.6%. Both of these levels are increased above
normal range with the normal range of Hgb A1c being <7% and a BG range of
<180mg/dL. Due to CF’s current BG and Hgb A1c levels, modification of his
current medications is necessary due to his poor management of Type II DM. Risk
factors for CF include age, African American, family history, HTN, obesity,
unhealthy diet, physical inactivity and sedentary lifestyle, history of cigarette use,
alcohol use, and uncontrolled BG levels. Because CF has many risk factors for
developing long-term complications of Type II DM, there will need to be a
change to his treatment plan. This new plan will include lifestyle change and
changing his current medication regimen. To do this, we also need to do a full
cardiac workup due to his mild JVD to include an echocardiogram, chest x-ray,
EKG, and cardiac enzymes to rule out cardiac disease which could be secondary
to his uncontrolled Type II DM.
Home Medications:
Glyburide 5mg QD
EC ASA 325mg QD
Altace 2.5mg QD
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CASE STUDY ANALYSIS: DIABETES
2. Determine appropriateness of current medications:
Glyburide- Appropriate treatment for DM but not controlling CF’s DM
(a) Indications: Type II DM indicates the need for non-insulin management; CF
needs a second line of treatment such as exercise, healthy diet, and weight loss
with the Glyburide to improve his BG levels.
(b) Interactions: When taking glyburide, it is important to avoid taking NSAIDS,
fluoroquinolones, sulfonamides, broad spectrum antibiotics, MAOIs, type 2
receptor antagonists, and anti-coagulants because these medications can cause
hypoglycemia (Burchum & Rosenthal, 2019). Pregnant or lactating women
should also avoid glyburide because it can have teratogenic effects. If the
patient is taking any kind of beta-blockers with glyburide, they will also need
to monitor their BG levels closely as these can cause hypoglycemia. When
prescribing glyburide to patients it is important to consider the patients age
and mental status (dementia, frequent confusion or forgetfulness) because
glyburide can cause prolonged hypoglycemic effects. Also, alcohol
consumption should be avoided due to headache, nausea, blurred vision,
anxiety, chest pain, and confusion.
(c) Drug Dosing: For patients CF’s age, it would be warranted to start with a
smaller dose than the average adult due to kidney function and compliance.
The average adult dose to start would be 2.5-5mg per day. The elderly should
start with 1.25-2.5mg orally once a day with breakfast. Then increase by
2.5mg once compliant or BG levels are not adequate. You can increase the
dose once per week. Maximum recommended does is 20mg/day divided into 2
times per day (breakfast and dinner) depending on medication tolerance
(Burchum & Rosenthal, 2019).
(d) Compliance: According to CF, he states he takes his glyburide every day with
breakfast, showing he is compliant with his medication regimen.
(e) Outcome: According to CF’s BG logs, his HgbA1c, and his random BG level
done in the office, it is evident that his BG is not well controlled. Due to CF
having an increased BMI, he drinks alcohol daily, and does not exercise, he is
considered non-compliant. Glyburide works well for someone who includes a
healthy diet and exercises daily, and tries to maintain a healthy weight. Due to
this and the fact that CF is older in age, a new hypoglycemic medication
should be prescribed. CF also needs to be educated on lifestyle changes such
as implementing a healthier diet, decreasing alcohol consumption, and
exercising daily. If these changes are implemented, CF should have a decrease
in his BMI which will help control his Type II DM. We will also implement a
goal for his HgbA1c to be less than 7.5% when he is seen in the office on his
next visit.
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CASE STUDY ANALYSIS: DIABETES
(f) Adverse Effect: CF needs to monitor for sustained hypoglycemia, which can
be a common side effect for glyburide. If CF does have sustained
hypoglycemia, he could have side effects such as thrombocytopenia, aplastic
anemia, hepatic failure, leukopenia, cholestatic jaundice, agranulocytosis, and
hepatotoxicity (Burchum & Rosenthal, 2019).
EC ASA- used in prophylaxis of myocardial infarction (MI) due to CF’s hx of
HTN, risk of stroke, and family hx of cardiac issues.
(a) Indication: Because CF has HTN, family hx of cardiac issues, his age, and his
social history of smoking, as well as being a high risk candidate for stroke r/t
Type II DM, EC ASA is prescribed as a prophylaxis for risk of MI.
(b) Interactions: Patients who have a history of bleeding, increased ICP, vitamin
K deficiency, anti-coagulation therapy, PUD, or active hepatic disease should
not take EC ASA. Taking EC ASA while drinking alcohol, on steroids, or
NSAIDS, or any anti-inflammatories can increase the risk for formation of a
GI ulcer. Medication effectiveness may be increased if taken in combination
with methotrexate, Depakote, Coumadin, insulin, or thrombolytics (Burchum
& Rosenthal, 2019).
(c) Drug Dosing: When taken as prophylaxis for MI/stroke the appropriate dose is
50-325mg per day orally. Due to CF’s comorbidities such as Type II DM, his
BMI, he is over the age of 40, family hx, and a hx of smoking, the
recommended does for him is 75-162mg per day orally (Burchum &
Rosenthal, 2019).
(d) Compliance: CF reports he takes his EC ASA daily every morning with
breakfast.
(e) Outcomes: According to the American Association of Clinical Endocrinology
(AACE), EC ASA 81mg orally daily is the recommended dose for patients
who have Type II DM and are at risk for cardiovascular disease (AACE,
2021). Lowering CF’s does still decreases his risk for development of an MI
or stroke and is shown to be just as effective has a higher dose of EC ASA, but
also lowers his risk for bleeding.
(f) Adverse Effect: Adverse effects of ASA include GI bleed, leukopenia,
hepatitis, hepatic failure, hemolytic anemia, neutropenia, agranulocytosis,
seizures, anaphylaxis, and laryngeal edema (Schwinghammer et al., 2021).
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CASE STUDY ANALYSIS: DIABETES
Altace- Appropriate treatment for HTN.
(a) Indication: CF has HTN, so being on this medication lowers his risk for an MI
and also is used as a prevention for diabetic nephropathy.
(b) Interactions: Elderly patients should take caution while taking this medication,
as well as patients with CHF, COPD, hypovolemia, impaired renal and hepatic
function, and renal artery stenosis. This medication should not be given to
patients who are on renal dialysis, patients on diuretics, or in conjunction with
other hypertensives due to the risk of hypotension. If the patient has an
increased sensitivity to ACE inhibitors or a history of ACE inhibitors causing
angioedema, avoid giving to patients. Patients who are on prazosin,
hydralazine, sympathomimetics, potassium-sparing diuretics, vasodilators, or
potassium supplements should not take this medication due to its increase in
the risk of toxicity (Burchum & Rosenthal, 2019).
(c) Drug Dosing: when starting this medication, 2.5mg orally is the daily dose.
Patients can go as high as 20mg daily or divided into two separate doses per
day (Burchum & Rosenthal, 2019).
(d) Compliance: CF explained he takes his Altace in the morning with all of his
medications during breakfast.
(e) Outcomes: During CF’s office visit, his BP was 145/84 mmHg. With a patient
who has Type II DM, the goal for BP is to be <140/90 mmHg. These levels
are right about where they should be and because of this we can continue his
current medication therapy for his HTN. Will need to make sure the patient
understands to check his BP daily before taking his medication and to keep
track of his BP’s for the next appointment so they can be monitored.
(f) Adverse Effects: Adverse effects of Altace include leukopenia, hepatic failure,
thrombocytopenia, anaphylaxis, toxic epidermal necrolysis, pancytopenia,
eosinophilia, hepatitis, angioedema, and Steven-Johnson syndrome
(Schwinghammer et al., 2021).
3. Additional Information Needed:
Dietary intake
Weight hx
Past HgbA1c levels
Hx of hypoglycemic episodes
Compliance hx
Exercise habits
Diabetes education hx
Any kind of health disparities such as cultural barriers, access to healthy
food options, and financial status
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CASE STUDY ANALYSIS: DIABETES
Patients willingness to learn and change habits, goals, and psychosocial
status
Fasting lipid profile (includes Total LDH, HDL, and Triglycerides)
Renal and Liver function tests, Serum Creatinine and GFR, and Urine
ketones
Cardiac panel, EKG, and chest x-ray
4. Desired therapeutic Outcomes:
(a) Short Term Goals of Treatment:
Prevent hypoglycemia episodes
Keep BP controlled at <140/90 mmHg
Decrease BG levels to 80-120 mg/dL
Decrease HgbA1c to less than 7.5% within the next 3 months
Exercise daily
Decrease BMI within next 3 months
Decrease alcohol intake
Healthier food choices
Check BG at least twice per day (morning and night) and record readings
Check BP daily and record readings
(b) Long Term Goals of Treatment:
Sustain fasting BG between 80-130 mg/dL
Keep BP levels less than 140/90 mmHg
HbgA1c level less than 7.0%
Total weight loss of >5% of primary body weight
Stop alcohol consumption
Prevent diabetic complications
D. Plan:
1. Recommendations:
(a) Non-pharmacological Therapy:
Make healthier food choices
Stop alcohol consumption
Exercise at least 3 days per week
Weight loss of at least 5% of initial body weight every 3 months until
at desired weight
Patient will need referrals to diabetic nurse educator, nutritional
specialist, and podiatrist for foot care due to diabetic neuropathy
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CASE STUDY ANALYSIS: DIABETES
Checking BG levels at home at least 2 times per day (morning and
night)
Make a follow-up for 4-6 weeks to re-evaluate medication changes and
check in on lifestyle changes mentioned
Re-check HgbA1c in 3 months
Lab work done every 4-6 weeks
Patient education on everything discussed in office including new
medications, lifestyle changes, and s/s of MI or stroke
(b) Pharmacologic Therapy:
With the non-pharmacological therapies recommended to CF, over the
next 3 months the patient will try to lower his HgbA1c to less than 7.5%.
If he is unable to do so, then metformin will be added to his medication
daily regimen instead of the glyburide. If, after another 3 months, his
HgbA1c goal is still not met, dual medication therapy will be initiated.
1) Metformin- oral anti-hyperglycemic
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CASE STUDY ANALYSIS: DIABETES
CF will be started on this as a monotherapy at first. If the patient has heart
failure or renal insufficiencies the provider should not prescribe this
medication. Renal function needs to be checked prior to starting
metformin and every few months while on it. Metformin works at its peak
when combined with adequate diet and exercise.
Oral Dose: 850 mg/day orally with breakfast when just starting; may
increase does by 500mg weekly and up to 2550mg/day (Burchum &
Rosenthal, 2019).
NEW MEDICATION: Metformin
E or
AE
Parameter Method Goal Alter Tx When/If
E Lower BG level
Self-monitoring 2x day
and log to report
Laboratory Results of
HgbA1c Q 3 months
Short term
HgbA1c of
<7.5%
BG between
80-130 mg/dL
Long term
HgbA1c of
7.0%
If HgbA1c is not
improved at 3
month check,
increase dose of
metformin and
monitor BG levels
AE Hypoglycemic
Reactions
Patient self-reports
Patient monitors BG
levels at home
To have no
hypoglycemic
events
If pt continues to
have
hypoglycemic
episodes, instruct
to take with meals
to counteract
AE Lactic Acidosis
Patient self-reports
symptoms
Labs- increased Lactic
level
No symptoms
of lactic
acidosis and
normal lab
values for
lactic level
If patient develops
s/s of lactic
acidosis, send to
ER for evaluation
AE Gastrointestinal
Upset
Patient self-reports
stomach issues
No GI upset
such as nausea,
vomiting,
diarrhea,
constipation,
or abdominal
pain
If patient has
these symptoms,
check BG levels
and make apt to
be seen in office
2) Glipizide- Oral hypoglycemic medication
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CASE STUDY ANALYSIS: DIABETES
If, after 3 months, CF’s HgbA1c has not reached the therapeutic goal with the
monotherapy of metformin, then glipizide will be added to the medication
regimen to work in combination with metformin. Glipizide has a shorter half-
life than glyburide does and a lower potency, making it the preferred
medication of choice for older patients. Patients with hepatic and renal
insufficiencies should not take glipizide.
Oral Dose: 2.5mg orally daily at least 30 minutes before breakfast. We can
increase the dose by 2.5-5mg after at least a week with a maximum of 40mg
orally daily (Burchum & Rosenthal, 2019).
NEW MEDICATION: Glipizide
3) Atorvastatin- anti-lipidemic
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E or AE Parameter Method Goal Alter Tx
When/If
E Lower BG levels
Self-monitoring 2x day and
log to report
Laboratory Results of
HgbA1c Q 3 months
Short term
HgbA1c of
<7.5%
BG between 80-
130 mg/dL
Long term
HgbA1c of 7.0%
If HgbA1c is not
improved at 3
month check,
increase BG
plasma level
checks
AE Gastrointestinal
Upset
Pt self-reports this
For the patient to
have no nausea,
vomiting,
constipation,
diarrhea, or
abdominal pain
If patient has
these symptoms,
check BG levels
and make apt to
be seen in office
AE
Hypoglycemic
Reactions
Patient self-reports
Patient monitors BG levels
at home
To have no
hypoglycemic
events
If pt continues to
have
hypoglycemic
episodes
AE
Cholestatic
Jaundice
Pt self-reports symptoms
such has dark urine,
“yellow skin”, light colored
stool
Physical assessment in
office
Lab results- liver panel
No symptoms of
cholestatic
jaundice with
normal liver
panel results
If patient has
symptoms and
increased liver
panel enzymes,
send to ER for
further workup
CASE STUDY ANALYSIS: DIABETES
There is a risk for cardiovascular abnormalities and side effects with type II
DM. By taking atorvastatin, CF will decrease his risk for cardiovascular
disease by decreasing his lipid levels. Patients with Type II DM over the age
of 40 are at an increased risk for cardiovascular disease and should include a
statin in their medication regimen to reduce the risk (Schwinghammer et al.,
2021).
Oral Dose: CF can take 40-80mg per day, will need a lipid panel to decide
what dose to start on (Burchum & Rosenthal, 2019).
NEW MEDICATION: Atorvastatin
E or AE Parameter Method Goal Alter Tx When/If
E
Lower
Cholesterol and
LDL levels
Lab results of lipid panel
LDL less than 100
Triglycerides less than
150
HDL greater than 40
If LDL level does
not improve,
increase statin
dose
AE
Gastrointestinal
Upset
Pt self-reports GI upset
For the patient to have
no nausea, vomiting,
constipation, diarrhea, or
abdominal pain
If patient has these
symptoms, lower
dose of statin or
stop completely
and make office
apt.
AE Arthralgia Pt self-reports joint pain Pt reports no joint pain
If pt still has joint
pain lower dose of
statin or stop
completely and
make office apt.
AE
Liver
Dysfunction
Lab results of liver panel
Lab results show normal
liver panel- AST, ALT,
LFT, Bilirubin
If lab values are
still increased,
lower dose of
statin or stop
completely and
make office apt.
AE Nasopharyngitis
Pt reports having fevers,
cough, runny nose and
nasal congestion
Physical exam
Pt has no cold-like
symptoms
Pt reports having
cold-like
symptoms, have pt
stop medication
and make an office
apt.
References
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CASE STUDY ANALYSIS: DIABETES
American Association of Clinical Endocrinology (AACE) (2021). AACE Comprehensive Type 2
Diabetes Management Algorithm. Retrieved from
https://pro.aace.com/pdfs/diabetes/AACE_2019_Diabetes_Algorithm_03.2021.pdf
Burchum, J. R. & Rosenthal, L. D. (2019). Lehne’s Pharmacology for Nursing Care (10th ed.) St.
Louis, MO: Elsevier.
Schwinghammer, T. L., Dipiro, J. T., Ellingrod, V. L., & Dipiro, C. V. (2021). Pharmacotherapy
Handbook (11th ed.) New York, NY: McGraw Hill Education
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