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 A1c 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 A1c, 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
 Opioid use with alcohol
 Obesity 10/2006
 HL 04/2007
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 T2DM 08/2008
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 Insomnia 07/2009
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 Impotence 12/09
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 PTSD 10/10
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 Alcohol dependence 12/11
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
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
 Aspirin EC



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
1000mg;po;BID
Glipizide
5mg;po;BID;WM
Simvastatin 40mg;po;HS
Metoprolol tartrate
100mg;po;BID
Topiramate 50mg;po;HS
Trazodone 100mg;po;HS




81mg;po;daily
MVI 1 tablet;po;daily
Glucose 4gm Chew 3
tabs;po;PRN;hypoglycemia
Clotrimazole
AAA;topically;BID
Acetaminophen 325mg
2 tabs;po;q6;PRN;pain
Ranitidine
150mg;po;BID;PRN;GERD
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 A1c 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 – Q4 tenderness, guarding
 Genit/Rect – deferred
 MS/Ext – No CC LLE on Rt leg, currently treated with
clotrimazole
 Neuro – A&O x3; CN2-12 intact
DD Labs (Date)
DD Exams
DD Problem List
 T2DM
 Alcohol Dependence
 β-Blocker Withdrawal
Type 2 Diabetes Mellitus (T2DM)
Problem #1
DD
 Managed on Metformin and Glipizide and lifestyle
modifications
 When his medication and regimen is working, his A1c is 66.9
 Upon last intake for alcohol intoxication, they discontinued
his regimen
 Last A1c in September was 8.7%
Diabetes
Not This
This
Risk Factors for Diabetes
 Age ≥45 years
 First-degree relative with diabetes
 Overweight with central obesity (BMI ≥25 kg/m2)
 Hypertension (BP ≥140/90 mm Hg )
 Treated for hypertension
 HDL cholesterol <35 mg/dL
 Triglyceride level >250 mg/dL
American Diabetes Association. Standards of medical care in diabetes—
2015. Diabetes Care 2015;30(Suppl 1):S4–S41.
Signs and Symptoms T2DM
 Polyuria
 Polydipsia
 Blurry vision
American Diabetes Association. Standards of medical care in diabetes—
2015. Diabetes Care 2015;30(Suppl 1):S4–S41.
Diagnosis of T2DM
 A1c
 ≥6.5%
 Fasting Plasma Glucose
 ≥126 mg/dL
 2 hour plasma glucos during an OGTT
 ≥200 mg/dL
 Random Plasma Glucose (w/ classic symptoms) or
Hyperglycemic crisis
 ≥200 mg/dL
 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):S4–S41.
Treatment Algorithm for Management
of T2DM
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. 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
 Tachycardia
 Deep tendon reflexes
Mayo-Smith MF. Pharmacological management of alcohol withdrawal: a meta-analysis and evidencebased 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 meta-analysis and evidencebased 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 minifridge.
 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

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


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.
Refer patient to dietitian for assistance with long-term
nutritional stability
Mayo-Smith MF. Pharmacological management of alcohol withdrawal: a meta-analysis and evidence-based
practice guideline. American Society of Addiction Medicine Working Group 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, B12, MVI
Beta Blocker Withdrawal
Problem #3
DD’s presentation
 Ran out of Metoprolol Tartrate 100mg
 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
E
T½
Atenolol
50%
Bioavailability
6-16% protein
binding
Hepatic
R: 50%
F: 50%
6-7h
Bisoprolol
80%
Bioavailability
30% protein
binding
Hepatic
R: 50%
9-12h
Carvedilol
25-35%
Bioavailability
Systemic (Vd
115L)
Hepatic
2D6
S: F/B
7-10h
Metoprolol
50%
Bioavailability
10% albumin
bound
Hepatic
2D6
R: 95%
3-4h
Propranolol
30-70%
Bioavailability
93% protein
binding
Hepatic
R: <1%
IR: 3-6h
ER: 8-20h
Sotalol
90-100%
No protein
Hepatic
R: 6612h
Bioavailability
binding
88% UC
Vd: Volume of Distribution; R: Renally Eliminated; F: Fecally Eliminated; S:
Systemically Eliminated; F/B: Fecally/ biliary; UC: Unchanged
Atenolol,Bisoprolol et .al. In: DRUGDEX Evaluations [database on the Internet]. Greenwood Village
(CO): Thompson Micromedex; 1974-2012 [cited 15 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-receptor-mediated
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
Thank You