Hypoglycemia & Management of Diabetes in CKD Stage V
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Transcript of Hypoglycemia & Management of Diabetes in CKD Stage V
Hypoglycemia & Management of Diabetes in CKD Stage V
PROBLEM BASED LEARNING (PBL)
PREPARED BY: MUHAMMAD ARIFF B. MAHDZUB
BACHELOR MEDICINE AND SURGERY (MBBS)
UNIVERSITY COLLEGE SHAHPUTRA, KUANTAN
Patient’s Demographics
Name
Ward
DOA
Weight
Race
Gender
Age
RN
LT
Female
Chinese
50kg
10 June 2013
7C, Bed E18
90 years old
5798
Chief Complaint
Unresponsive, found by family members.+ Heavy sweating, cold extremities, nausea, dizziness, chest discomfort, palpitationNo vomiting, headache, URTI or UTI symptoms, fever
History of Present Illness
• Poor oral intake• Due to toothache for the past 2 days,
throbbing in nature• Despite that, patient still continue metformin
and actrapid injections.
Past Medical History
• Diabetes Mellitus• Hypertension under KK Bkt Sekilau• Ischemic Heart Disease• ? Diastolic Dysfunction - under cardio (EF = 72%,
good LV function)
Past Medication History
• T. Hydrochlorothiazide 50mg od• T. Ticlopidine 250mg bd• T. Spironolactone 12.5mg od• T. Bisoprolol 1.25mg od • T. Omeprazole 40mg od• T. Perindopril 4mg od• T. Metformin 500mg bd• S/C Actrapid 6 units bd
Review of System
• BP : 119/52• PR : 72• RR : 20 breaths per min• T : 37°C• Dxt : 1.2 mmol/L
Social/Family History
• Married• Lives with grandchildren.• Does not smoke, imbibe alcohol or abuse
drugs.
• Hypoglycemia secondary to toothache and poor oral intake
• Underlying hypertension, diabetes mellitus, IHD
• Stage V CKD• CAP
Diagnosis
Vital Sign
Temperature
Lab Investigation and Findings
Parameter Normal range D1 D2
10/6
TWBC 4-11 x10/L 10.99
Hb 13-17 g/100ml 11.6
Platelet 150-400 x 10/L 169
FBC
Lipid Profile
Parameter Normal range D3
12/6
LDL-C < 2.5 mmol/L 3.44
HDL-C >1.1 mmol/L 0.98
TG <1.7mmol/L 0.67
Lab Investigation and FindingsParameter Normal
rangeD1
10/6
Urea 3.2-7.3 29.8
Na 136-146 133
K 3.5-5.1 3.9
Cl 98-106 101
SCr 59-104 206
Crcl 105-150 12.6
BUSE/ Renal Profile
Dextrose Chart
Dextrose 50% 50ml + 1 pint D5
Ward Medications
Antibiotics Date Start
Date Stop
Indication
IV Augmentin 1.2g stat & TDS (not served)
10/6 10/6
Suspected CAPT. Azithromycin 500mg stat & OD(not served)
10/6 10/6
Ward MedicationsOther Medications Date
StartDate Stop
Indication
T. Ticlopidine 250mg bd (not served)
10/6 10/6 IHD
T. Spironolactone 12.5mg od 10/6 10/6
HypertensionT. Hydrochlorothiazide 50mg od 10/6 10/6
T. Perindopril 4mg od 10/6 -
IV Frusemide 40mg bd 10/6 -
T. Bisoprolol 1.25mg od 10/6 - IHD, HF
T. Omeprazole 40mg od 10/6 - Stress ulcer prophylaxis
T. Bromhexine 8mg tds 10/6 Cough
T. Paracetamol 1g prn 11/6 Pain
IV Metoclopramide 10mg prn 11/6 Nausea
Ward Medications
Other Medications Date Start Date Stop Indication
S/C Actrapid 6 units tds 11/6 13/6
DMS/C Insulatard 6 units ON 11/6 13/6
T. Gliclazide 40mg bd 13/6
Pharmaceutical Care Issues
Diabetes in CKD
Hypoglycemia
Diabetes in CKD
Description Management Plan
Definition: Diabetes - a state of chronic hyperglycaemia caused by insulin insufficiency or resistance. Is a leading cause of CKD, which occurs d/t augmentation of ECM.
Sign & symptoms:•Polydipsia•Polyuria•Polyphagia•Blurred vision•Weight loss•Hyperglycaemia•Nocturia•Malaise/fatigue•Persistent albuminuria•Decline in GFR•Elevated arterial bp
Special considerations in the CKD Population
Management
Metformin was witheld. Actrapid and insulatard was initiated on 11/6 and was switched to gliclazide 40mg bd on 13/6 after dental procedure on patient’s request.
CommentManagement of DM was appropriate. Although the Malaysian CPG (2009) recommends to avoid gliclazide in patients with CrCl < 30ml/min, the KDOQI Diabetes Guidelines (2012) recommends gliclazide as it does not have active metabolites and do not inc the risk of hypo in patients.However, management of comorbidities such as hyperlipidaemia is inadequate (refer to DRP)
Monitor•Dxt
(CPG: Management of chronic obstructive pulmonary disease, Nov 2009, Ministry of Health of Malaysia)
Special Considerations in CKD Patients1,2
• Higher risk of hypoglycemia (see next PCI).– Decreased excretion of insulin & OHAs– Impaired renal gluconeogenesis with reduced kidney
mass.
• Fall in excretion of certain drugs (see DRP)– Adjustment of doses– Unsuitability of use of certain drugs
1. KDOQI Clinical Practice Guidelines for Diabetes and CKD: 2012 Update2. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes in Chronic Kidney
Disease 2006
Hypoglycemia
Hypoglycemia
A/E 8C
• IV Aminophylline 250mg over 8H
• S/c Terbutaline 0.5mg stat
• IV Hydrocortisone 200mg stat
• IV Hydrocortisone 100mg QID
• T. Theophylline SR 250mg BD
• T. Prednisolone 30mg OD
• Neb combivent 4-6H
Description Management Plan
Definition:Blood glucose level of less than 3.9 mmoml/L (American Diabetes Association, European Medicines Agency)
Causes:•OD, ill-timing or wrong type of insulin and OHA•↓ clearance of insulin or OHA d/t renal impairment.•Reduced oral intake.•Improved insulin sensitivity.•Critical illness•Drugs, tumours & hormonal deficiency.
Symptoms:1)Autonomic – shaking, trembling, sweating, palpitations, paresthesia, anxiety2)Neuroglycopenic - cognitive dysfunction, behavioural changes, seizures, coma, death
Recommended managementFully conscious patient: oral glucose, sucrose or sugar containing fluids. Ensure adequate food intake to prevent subsequent relapses.
When mental function is impaired: IV 50% dextrose 25-50ml until mental function recovers or blood glucose = normal, then infusion of 5-10% dextrose or a glucose drink if patient regains consciousness.If hypoglycemia d/t long acting insulin or OHA, 5-10% dextrose drip should be continued for 24-48 h.Glucagon 1mg IM/SC can be given to treat severe hypoglycemia when IV access is difficult. Patient who remain unconscious after prolonged hypoglycemia may need to be given treatment for cerebral oedema with IV dexamethasone 4mg 6hrly or IV mannitol.
ManagementPatient administered 50ml of dextrose 50% in A&Ewhich was continued with 1 pint dextrose 5% in the 7CInsulin and metformin was witheld.Blood sugar = 19 mmol/L.QID dxt was instituted.Counselling was given to patient’s family by pharmacist.
Comment:Management was appropriate.
Monitor:-Dxt
(CPG: Management of chronic obstructive pulmonary disease, Nov 2009, Ministry of Health of Malaysia)
Drug Related Problems
Inappropriate use of drugs in CKD Stage V
Inadequate regimen of statins
Inappropriate discontinuation of ticlopidine for tooth extraction
Issue Justification Suggestion
Patient has a CrCl of 12.8 upon admission. Patient was previously on T. hydrochlorothiazide 50mg od & T. metformin 500mg bd and her old medication was planned to be continued in the ward. In addition patient was also started on IV Augmentin 1.2g tds on 10/6.
According to Malaysian Clinical Practice Guidelines for Diabetes Mellitus (2009), metformin should not be administered in patients with a CrCl < 30ml/min. This is because it is cleared by the kidneys and may build up, leading to an increased risk of lactic acidosis.
Thiazide diuretics are generally relatively ineffective in patients with GFR < 30ml/min. A loop diuretic is preferred.
According to the National Antibiotic Guideline 2008, Augmentin should be reduced to a bd dosing.
Suggestion:To ensure Metformin not restarted & to start on insulin if indicated when hypoglycemia resolved.
To off thiazide diuretics and replace with loop diuretics if indicated.
To suggest a dose reduction of Augmentin to 1.2g bd.
Outcome:Metformin was not restarted. Pt started on S/C Actrapid & Insulatard on the 11.6.
HCTZ was off and replaced with IV frusemide.
Augmentin 1.2g tds was off on 10/6 (d/t ruling out of CAP).
Inappropriate Drug Use in CKD Stage V
Issue Justification Suggestion
Patient has an elevated LDL-C of 3.44 mmol/L (target < 2.56 mmol/L) and is not on any therapy.
The use of statins are recommended in patients with diabetes and hypertension regardless of baseline cholesterol levels.
From the Pravastatin Pooling Project, persons with diabetes and CKD had the greatest risk of CVD death, MI or revascularization procedures compared to those with either condition alone or neither condition. They also had the largest absolute risk reduction with statin.
Suggestion:Suggest to initiate T. Simvastatin 20mg ON (estimate 38% in LDL-C to reach 2.13 mmol/L)
Outcome:To notify dr. Simvastatin 40mg ON has been initiated at discharge.
Inadequate Regimen of Statins
Inappropriate Discontinuation of Ticlopidine
Issue Justification Suggestion
Patient’s ticlopidine was stopped in view of her tooth extraction.
Bleeding complications, while inconvenient, do not carry the same risks as thromboembolic complications. Patients are more at risk of permanent disability or death if they stop antiplatelet medication prior to a surgical procedure than if they continue it. Published reviews of available literature advise that antiplatelet monotherapy should not be stopped prior to dental surgical procedures. Post operative bleeding following dental procedures are minimal, easily visualized, has minor consequences to the patient and can be controlled using local hemostatic measures.
Suggestion:To restart Ticlopidine in the ward.
Outcome:Ticlopidine was restarted at discharge. Patient did not suffer any thromboembolic complications or bleeding.
Roles of DMTAC Pharmacist
• Patient insulin pen technique To evaluate and counsel patient to ensure that the correct
dose of insulin is administered.
• Hypoglycemia How to avoid hypoglycemia Recognition and management of hypoglycemia Sick day management SMBG
References• United Kingdom National Health Service. Surgical management of the
primary care dental patient on antiplatelet medication. National Electronic Library of Medicines. Accessed 13 June 2013.
• Jaffer AK. Perioperative management of warfarin and antiplatelet therapy. Cleveland Clinic Journal of Medicine 2009;76(4):S37-44.
• Wan Mohamad WB, et al. Management of Type 2 Diabetes Mellitus. 4 th ed. Malaysia: Ministry of Health Malaysia;2009.
• Clinical Practice Guidelines: Management of dyslipidaemia. Malaysia: Ministry of Health Malaysia;2003.
• Smith SC, et al. AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update: Endorsed by the National Heart, Lung, and Blood Institute. Circulation 2006;113;2363-2372.
• Hua HS, et al. Sarawak Handbook of Medical Emergencies. Third Edition
esophageal varicesTHANK YOU