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

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