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HS2130

PRESENTED BY:
Cristine Joy Ponseca Alcones
OBJECTIVES
1. Define hypertension and identify the risk factors and
complications of hypertension.
2. Define Diabetes Mellitus, outline the risk factors.
3. Discuss the current medications prescribed
• Glipizide
• Metformin
• Beta Methasone
4. Explain the rationale for starting Mrs Goh on insulin therapy.
5. Discuss Prednisolone and the responsibilities in administering
it.
6. Explain the rationale for the discontinuation of Prednisolone .
7. Discus the mechanism of action and key patient education
points with regards to Mrs Goh’s oral anti diabetic drugs.
CASE STUDY
Name :Mrs Ivy Goh
Age : 66
Gender : Female
Ethnic : Chinese
Date of Admission : 22nd of May
Drug Allergy: NKDA
Social History :House wife, stays with her son’s family. Helped to look after four
grandchildren during weekdays. Occasionally visits the casino during the weekends.
Medical History : Well controlled DM for the past 9 years, severe dermatitis
(developed about two weeks ago) due to the unknown application of topical medication
for the rashes on her back. Doctor prescribe prednisolone and beta metasone 1%.
Chief Complaints :
•Passing of abnormally large quantity of urine, especially at night.
• Accompanied with the need of drinking large amount of water.
•2 days ago She complained that her vision is blurring with this she constantly have to
rub her eyes as she had difficulty focusing.
CASE STUDY
Physical Examination:
•Blood Pressure 146/82
•13.8 mmol/L (2 HR post prandial blood glucose level)
•12 ECG – no signs of myocardial infarction.
•Chest X-ray – no evidence of cardiomegaly
Impression/Diagnosis
•Hypertension
•Diabetes Mellitus
Current Medication
•Betamethasone 1% cream om
•Glipizide 5mg BD
•Metformin 850 TDS
•Prednisolone 20mg OM
Treatment
•Stop Prednisolone immediately, start short term insulin therapy
HYPERTENSION
Definition
Medical condition in which increase force that moves blood around the body

Risk factors
high blood overweight (BMI of
smoker DM
cholesterol levels 23kg/m2 or higher).

Complications
coronary heart
heart failure stroke arteriosclerosis kidney failure
disease
DIABETES MELLITUS
• Diabetes is a chronic disease, which occurs when
the pancreas does not produce enough insulin, or
when the body cannot effectively use the insulin it
produces. This leads to an increased concentration
of glucose in the blood (hyperglycaemia).
SIGNS AND SYMPTOMS OF
DIABETES MELLITUS
• Unusual thirst (polydipsia)
• Excessive hunger (polyphagia)
• Frequent urination (polyuria)
• Unusual weight loss (emaciation)
• Extreme fatigue or lack of energy
• Blurred vision,
• Frequent or recurring infections,
• cuts and bruises that are slow to heal,
• tingling &/or numbness in hands &/or feet.
TYPES OF DIABETES
MELLITUS
Type 2:
(formerly called non-insulin-dependent or adult-onset diabetes) is caused
by the body’s ineffective use of insulin. It often results from excess body
weight and physical inactivity.

Risk factors:
• Obesity, family history
• Age group >35

CAN BE CONTROLLED BY DIET, EXERCISE AND MEDICINES, IF


THIS FAILED INSULIN INJECTION IS NECESSARY.
GLIPIZIDE 5mg BD
Class :Anti diabetic agent, Sulfonylurea
Brand name : Glucotrol , Glucotrol XL
Administrations : Administer immediate release tablets 30 minutes
before a meal.
Indications : Management of type 2 DM
Mechanism of actions: Stimulates insulin release from the pancreatic
beta cells, reduces glucose output from the liver, insulin sensitivity is
increased at peripheral target sites.
Side Effects : Diarrhea, headache, indigestion, mild stomach pain,
Nausea, stomach upset, vomiting.
Adverse Drug Reactions: Edema,Anxiety, depression, Cholestatic
jaundice , aplastic enemia, Rhinitis, Diaphoresis
METFORMIN 850mg TDS
Class :Anti diabetic agent, Biguanides
Brand name : Fortamet, Glucophage, Riomet, Glumetza
Administrations :Extended release dosage form should be swallowed
whole, do not crush, break or chew.
Indications :Management of type 2 DM as monotherapy when
hyperglycemia cannot be managed on diet alone.
Mechanism of action: Decreases hepatic glucose production, decreases
intestinal absorption of glucose and improves insulin sensitivity.
Side Effects :Diarrhea, nausea, headache , weakness, indigestion,
abdominal discomfort and gas.
Adverse Drug Reactions: Flushing, Palpitations, Hypoglycemia,Rash.
PRECAUTIONS: It may cause Lactic acidosis
BETAMETHASONE
1% ON
Class :Corticosteroid, Systemic Corticosteroid, Topical.
Brand name : Beta-Val, Celestone, Diprolene , Soluspan.
Administrations : Topical
Indications :Inflammatory dermatoses such as seborrheic or atopic dermatitis,
neurodermatitis, anogenital pruritus, psoriasis.
Mechanism of actions: Binds to corticosteroid receptors in cell and acts to prevent
or control inflammation.
Side Effects : Acne, clumsiness, dizziness, facial flushing, general body discomfort,
headache, increased appetite, increased sweating, lightheadedness, nausea,
nervousness, pain, swelling, or redness at the injection site, sleeplessness, upset
stomach.
Adverse Drug Reactions: Congestive heart failure, Glaucoma, Skin atrophy,
vesiculation, folliculitis.
WHY DID MRS GOH HAS TO
START INSULIN INJECTION?
13.8 mmol/L (2 HR post prandial blood glucose level)
TARGET OF GLYCAEMIC CONTROL (MOH CLINICAL PRACTISE GUIDELINES 2006)
TEST OPTIMAL SUBOPTIMAL UNACCEPTABLE
(target goal for (adequate goal for (action needed in all
majority of patients) some patients) patients)

HbA1C (%) 6.5-7.0 7.1-8.0 >8.0

Pre-meal glucose 6.1-8.0 8.1-10.0 >10


(mmol/L)

2- hour post meal 7.1-10.0 10.1-13.0 >13.0


glucose (mmol/L)
TYPE 2 DIABETES FOR NON OBESE PATIENT
Diet and exercise

CONTROLLED NOT CONTROLLED

START SULFONYLUREAS

CONTROLLED
NOT CONTROLLED WITH ADEQUATE DOSAGE

ADD METFORMIN OR THIAZOLIDINEDIONES OR ARCABOSE

CONTROLLED NOT CONTROLLED WITH ADEQUATE DOSAGE

ADD INSULIN OR SWITCH TO FULL INSULIN


REPLACEMENT
PREDNISOLONE 20 mg OM
Class :Corticosteroids, Ophthalmic, Corticosteroid, systemic.
Brand name : Orapred , Econopred, Pediapred.
Administrations : Oral formulation with food or milk to decrease GI effect.
Indications : Treatment of dermatological, gastrointestinal, collagen diseases.

Mechanism of actions: Decrease inflammation by suppression of migration of


polymorphonuclear leukocytes and reversal of increased capillary permeability, suppresses
the immune system by reducing activity and volume of the lymphatic system, suppresses
adrenal function in high dose.

Side Effects :  fluid retention, weight gain, high blood pressure, potassium loss, headache,


muscle weakness, puffiness of and hair growth on the face, thinning and easy bruising of
the skin, glaucoma, cataracts, peptic ulceration, worsening of diabetes

Adverse Drug Reactions: Cardiomyopathy, Bruising, petechiae, Cushings syndrom,


diabetes mellitus, abdominal distention, malaise, hypokalemia, loss of accomodation, optic
nerve damage, cataract formation
Contraindications
–Hypersensitivity to Prednisolone
–Acute superficial herpes simplex keratitis
–Systemic fungal infections, varicella
Drug Interactions
Anticoagulants Antidiabetic Agents.
 
Points to note to the patient:
1.Since the patient has diabetes mellitus , the blood sugar level must be
monitor.
2.Small frequent meals to reduce GI upset.
3.Note any vision changes
WHY DID MRS GOH HAS TO
STOP USING
PREDNISOLONE?
• Systemic corticosteroids increase blood glucose levels; a potential
pharmacodynamic interaction exists between corticosteroids and all
antidiabetic agents.
• Diabetic patients who are administered systemic corticosteroid
therapy may require an adjustment in the dosing of the anti diabetic
agent.
• Blood lactate concentrations and the lactate to pyruvate ratio
increased when metformin was co-administered with the systemic
corticosteroids. Therefore it Elevated lactic acid concentrations are
associated with an increased risk of lactic acidosis.
Patient Education on
Metformin and Glipizides
• Do not take any medication, change dose or discontinue during therapy unless
consulted by their doctors.
• Avoid alcohol as it may cause severe reactions.
• As the medication may cause dizziness ask patient not to drive or to be near
potential hazardous that will cause them to fall or injure themselves.
• Take small frequent meals to prevent nausea and vomiting
• The patient must be able to recognize signs of hypoglycemia such as palpitations,
sweaty palms, lightheadedness)
• Always bring sweets as patient may experience hypoglycemia.
• Make sure that glipizides is taken 30 minutes before meal
• Report any signs of skin rashes.
CONCLUSION
• The elevating Diabetes Mellitus Disease of Mrs Goh causes her to feel more thirsty,
have blurred vision and to keep urinating. Though metformin and glipizide are
administered, the expected blood glucose level for her did not decrease therefore
combination of insulin with the oral anti diabetic agent has ordered as a last resort.
• Combination of metformin and systemic corticosteroids increased the chance for
lactic acidosis to occur,

• It also causes to increase the blood sugar level in the blood as a result elivation of
the diabetes mellitus will occur.
• Prednisolone has a drug interaction with the anti diabetic drugs
therefore the doctor ordered to stop taking this medication.

• The main important key point when educating the patient taking glipizide is to take
it 30 minutes before the meal to achieve better result
• The patient must know the signs of hypoglycaemia such as sweaty palm.
• Avoidance of alcohol is necessary to prevent elevation of blood sugar level.
REFERENCES
• Minitry of Health (2006). MOH clinical practise guideline: Diabetes mellitus.
Singapore: Ministry of Health.

• Dunning, T. (1998). Care of people with diabetes. London: Blackwell Science


Ltd.

• Medicinenet,1997, Medications and Drugs [On-line].


http://www.medicinenet.com/prednisolone/article.htm (1 July 2010) 

• Drugs,2008,Aspirin [On-line]. http://www.drugs.com/metformin.html (1 July


2010)

• Turkoski, B. B., Lance, B. R., & Bonfiglio, M. F. (2008). Drug Information


Handbook for Nursing (9th ed.). Canada: Lexi- Com, Inc.

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