EXERCISE NO.

7
CASE ON DIABETES MELLITUS TYPE 2

Type 2 diabetes is a chronic disease. It is characterized by high levels of sugar in the

blood. Type 2 diabetes is also called type 2 diabetes mellitus and adult-onset diabetes.
That's because it used to start almost always in middle-and late adulthood.

OBJECTIVES: At the end of this exercise, the students should be able to:
1) Recognize the signs, symptoms, and risk factors associated with Type 2 diabetes
mellitus (DM).
2) Identify the comorbidities in Type 2 DM associated with insulin resistance (metabolic
syndrome).
3) Compare the pharmacotherapeutic options in the management of Type 2 DM
including mechanisms of action, contraindications, and side effects.
4) Describe the role of self-monitoring of blood glucose (SMBG) and identify factors to
enhance patient adherence.
5) Develop a patient-specific pharmacotherapeutic plan for the treatment and monitoring
of Type 2 DM.

CASE

Chief Complaint: “I was recently diagnosed with possible diabetes and would like to
have my blood sugar tested. I think that my blood sugar is running low because I have a
terrible headache.”
HPI: Sarah Martin is a 43-year-old woman who comes to the pharmacy for a diabetes
education class taught by the pharmacist. She would like for the pharmacist to check
her blood sugar before the class begins. She was diagnosed with diabetes mellitus
Type 2 about 6 months ago. She has been attempting to control her disease with diet
and exercise but has had no success. Her physician has recently started her on
glyburide 5 mg. She has gained 15 lb over the past year. She monitors her blood sugar
once a day, per her physician, with a range of 215–260 mg/dL. Her fasting blood sugars
p 170 mg/dL.
PMH: Type 2 DM × 6 months, HTN × 15 years, Bipolar disorder × 25 years,
Dyslipidemia × 10 years, Morbid obesity × 15 years
Family History: Father has a history of HTN and bipolar disorder. Mother has a history
of dyslipidemia. Brother has DM secondary to alcoholism.
Social History: Has been married for 21 years. She has two children who are
teenagers. She works in a floral shop making deliveries. Denies any use of tobacco
products but does drink alcohol occasionally (five beers/wine per week).
Meds: Glyburide 5 mg po BID, Lisinopril 20 mg po once daily, Zyprexa 5 mg po Q HS,
Carbamazepine 200 mg po TID, Lorazepam 1 mg po TID PRN, Fluoxetine 20 mg po Q
AM, EC ASA 81 mg po once daily, Pravastatin 40 mg po once daily.

Allergies: Morphine—hives

Review of Systems: Complains of nocturia, polyuria, and polydipsia on a daily basis.

Denies nausea, constipation, diarrhea, signs or symptoms of hypogly-cemia,
paresthesias, and dyspnea.
Physical Examination:
Gen: WDWN severely obese, Caucasian woman in NAD
VS: BP 165/90, P 98, RR 18, T 38.6°C; waist circ 38 in, Wt 109 kg, Ht 5'8''
HEENT: PERRLA, EOMI, R and L fundus exam without retinopathy
Neck/Lymph Nodes: WNL
Lungs: Clear to A & P
CV: RRR, no MRG
Abd: NT/ND
Genit/Rect: Deferred
MS/Ext: Carotids, femorals, popliteals, and right dorsalis pedis pulses 2+ throughout;
left dorsalis pedis 1+; feet show mild calluses on MTPs
Neuro: DTRs 2+ throughout, feet with normal sensation (5.07 monofila-ment) and
vibration

Laboratory test
 WORKSHEET

PATIENT THERAPEUTIC CARE PLAN RECORD

Patient Name: Sarah Martin Gender: Female

Address: Age: 43

Birthdate: 1978

Medical Condition: Type 2 Diabetes Race: Caucasian

Mellitus

Tobacco/Alcohol/Substance Use: Beer and Weight: 109 kg

wine

Allergies: Morphine - hives Height:5’8 ft

DRUG INDICATION STRENGTH REGIMEN ADVERSE DRUG

NAME REACTIONS
Glyburide Oral diabetes 1.25 mg to 20 2.5 mg to 5 mg ● low blood sugar
medicine that helps mg orally ● nausea, heartburn,
control blood sugar feeling full;
levels. ● muscle or joint pain;
● blurred vision; or
● mild rash or skin
redness.

Lisinopril High Blood 20 mg to 40 5 mg to 10 mg ● headache, dizziness;

Pressure, used to mg ● cough; or
treat congestive ● chest pain
heart failure in
adults, or to improve
survival after a heart
attack.

Zyprexa Indicated for the 10 mg to 20 5 mg ● weight gain (more

treatment of mg common in
schizophrenia, teenagers),
Bipolar I Disorder ● increased appetite,
(Manic or Mixed ● headaches,
Episodes), ● dizziness,
● drowsiness,
● feeling tired or
restless,
● problems with speech
or memory,
● tremors or shaking,
● numbness or tingly
feeling,
● personality changes,
 ● dry mouth,
● increased salivation,
● stomach pain,
● constipation, and
● pain in your arms or
legs

Carbamaze Used to treat bipolar 800 - 1200 200 mg ● dizziness, loss of

pine disorder. mg/day coordination,
problems with walking;
● nausea, vomiting; or
● drowsiness.

Lorazepam Used to treat anxiety 1 mg to 2 mg 2 mg to 3 mg ● dizziness, drowsiness;

● weakness; or
● feeling unsteady.

Fluoxetine Used to treat major 20 mg to 60 20 mg ● sleep problems

depressive disorder, mg (insomnia), strange
bulimia nervosa (an dreams;
eating disorder), ● headache, dizziness,
obsessive- drowsiness, vision
compulsive disorder, changes;
panic disorder, and ● tremors or shaking,
premenstrual feeling anxious or
dysphoric disorder nervous;
(PMDD). ● pain, weakness,
yawning, tired feeling;
● upset stomach, loss of
appetite, nausea,
vomiting, diarrhea;
 ● dry mouth, sweating,
hot flashes;
● changes in weight or
appetite;
● stuffy nose, sinus
pain, sore throat, flu
symptoms; or
●
● decreased sex drive,
impotence, or difficulty
having an orgasm.

Pravastatin used together with 40 mg to 80 40 mg ● muscle or joint pain;

diet to lower blood mg ● nausea, vomiting,
levels of "bad" diarrhea;
cholesterol (low- ● headache; or
density lipoprotein, ● cold symptoms such
or LDL), to increase as stuffy nose,
levels of "good" sneezing, sore throat.
cholesterol (high-
density lipoprotein,
or HDL), and to
lower triglycerides (a
type of fat in the
blood)
ASSESSMENT, PLAN AND FOLLOW-UP EVALUATION

Medical Condition Drug-Therapy Goal, Current Follow-up Plan

Problem Status and
Interventions

Diabetes Mellitus She has gained 15 The patient reports Explore the
Type 2 lb over the past that she exercises patient's
year. at most once a understanding of
week and her diet is the need for good
Blood sugar is difficult to maintain glucose control.
running low due to due to the nature of Assist him in
a terrible headache her job as a delivery adopting necessary
Complaints of person. Her lifestyle changes
nocturia, polyuria, glycemic control and encourage pro-
and polydipsia on a has been active self-
daily basis. Denies maintained with an management.
nausea, 8.9% Hg A1c 6 These include
constipation, months ago. She smoking cessation,
diarrhea, signs or has had a moderate weight reduction,
symptoms of weight gain of 15 lb appropriate diet
hypogly-cemia, (6.8 kg) over the and exercise.
paresthesias, and past year. Her blood
dyspnea. pressure and
cholesterol are not
at goal on the
 current drug
therapy.

PATIENT COUNSELLING

Mrs. Martin should balance her diet and start eating healthy foods. I would also
like to ask you to cut drinking beer and wine because you have type 2 diabetes
mellitus and it is hard to secrete insulin. Always stay hydrated by drinking water
only. Together with balance exercise you should also perform physical activities to
help manage your blood pressure. Adjust diabetes treatment and plan as needed.
If you have encountered a medication problem, report it to your doctor
immediately. Lastly, make sure to take medicines as prescribed by your physician.
QUESTIONS:
1) What are this patient’s drug therapy problems?
The patient has gained 15 lb over the past year. And also her blood sugar is running low
due to a terrible headache. She also complains of nocturia, polyuria, and polydipsia on
a daily basis. Denies nausea, constipation, diarrhea, signs or symptoms of hypogly-
cemia, paresthesias, and dyspnea.

2) What findings indicate poorly controlled diabetes in this patient?

● Sarah Martin's blood glucose level is quite high, despite the fact that she is
already taking an oral anti-diabetic medication in conjunction with non-
pharmacological measures such as good nutrition and exercise. Furthermore, the
patient has gained weight. As a result of comorbidities, a variety of
pharmacological interactions have been discovered.
● A glycosylated hemoglobin is a sign of poorly treated diabetes. (HbA1c) of more
than 7% preprandial capillary plasma glucose 13omg/dl and peak Postprandial
capillary plasma glucose level of 180 mg/dl.

3) What are the goals of treatment for Type 2 diabetes in this patient?
● The patient requires regular monitoring and ongoing treatment to maintain
normal or near-normal blood sugar levels and Changes in diet. It is also
important to stop drinking alcohol to avoid risk of complications.
4) What non-pharmacologic interventions should be recommended for this patient’s
drug therapy problems?
Nonpharmacologic approaches include; diet modification, weight control, Healthy eating
and regular exercise.
5) What pharmacotherapeutic regimen would you recommend for each of the patient’s
drug therapy problems?
Pharmacologic approaches must be based on patient characteristics, level of glucose
control and cost considerations. Combinations of different oral agents may be useful for
controlling hyperglycemia before insulin therapy becomes necessary.

6) What parameters should be monitored to evaluate the efficacy and possible adverse
effects associated with the optimal regimens you selected?
The pharmacist may offer advice on how to monitor glucose levels and manage out-of-
range values, as well as establish an action plan for what to do if sugar levels go too
low. On an individual basis, pharmacists can assist patients in selecting the most
effective hypoglycemia treatment plan. Furthermore, pharmacists can provide advice on
an adequate diet and exercise program to supplement drug management in the
treatment of diabetes.The variety of diabetic treatment alternatives has risen
significantly in recent years, and pharmacists are best positioned to help patients grasp
the foundations and subtleties of the prescription, as well as which treatments may be
most suited for them. Pharmacists can also assist patients manage unwanted effects,
such as when and how to treat them so that medication can be continued and when it
may be best to transition to a different treatment regimen. It is also required to have an
eye exam to detect any retinal abnormalities, to have urine tests to detect the presence
of protein, to have foot checks to prevent foot ulcers, and to have other necessary blood
tests.
References:
Treatment of Type 2 Diabetes Retrieved from Mellitus
Https://www.aafp.org/afp/1999/0515/p2835.html
Wexler, D.J, M.D. (2020) Patient education: Type 2 diabetes: Treatment (Beyond the
Basics) Retrieved from https://www.uptodate.com/contents/type-2-diabetes-treatment-
beyond-the-basics/print

Florence, J.& Yeager, B. (1999). Treatment of Type 2 Diabetes Mellitus. Am Fam

Physician, 59(10):2835-2844. Retrieved from
https:/www.aaip.org/afp/1999/0515/p2835.html

Nguyen. Q. Nguyen, L.. & Felicetta, J. (2008). Evaluation and management of diabetes
mellitus. American health & drug benefits, 1(39-48)