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MUR case study: 64-year-old bus driver

Irregular hours are exacerbating your patient's hypertension and diabetes. What advice can you give him?

Roger Johnson is a 64-year-old bus driver with a BMI of 29kg/m2 and a history of type 2 diabetes, hypertension and hyperlipidaemia. He calls into the pharmacy to pick up his medicines.

Mr Johnson visited his GP for a health review last week, when his antihypertensive medicine ramipril was increased from 1.25mg to 5mg because of a raised blood pressure in clinic. He agrees to have an MUR in the pharmacy.

His current Rx is:

  • Aspirin 75mg GR OD
  • Amlodipine 5mg OD
  • Ramipril 5mg OD
  • Metformin 500mg BD
  • Simvastatin 40mg nocte
  • Blood glucose test strips
     

Below is an excerpt from Mr Johnson's MUR form:

Medicine

Taken as directed?

Comment

Aspirin 75mg GR OD

Yes

-

Amlodipine 5mg OD

Yes

-

Ramipril 5mg OD

Yes

Dizziness since new dose

Metformin 500mg BD

No – not with meals

Side effects reported

Simvastatin 40mg nocte

Yes

-

Blood glucose test strips

Not used

Patient unsure of when to test and how to interpret results

Ibuprofen 400mg tablets

Not prescribed

Taken occasionally for back pain

 

Main action points

Issue

Since starting his new dose of ramipril (5mg), Mr Johnson has experienced dizziness and light-headiness.

Recommendation

Mr Johnson should be made aware that when starting an ACE inhibitor, first-dose hypotension may occur.

For consideration by

GP/patient It can be best to take a new/higher dose of ramipril in the evening. If side effects do not improve, Mr Johnson should see his GP to have his dose reviewed because it may be too high. A 24-hour tape would give a better picture of his systolic/diastolic blood pressure.

Issue

Mr Johnson tries to take his metformin twice daily: at 8am with the rest of his morning medicines and at 10pm with his night time tablet. However, during the week when he is working he doesn’t eat until 11am and has dinner at around 7pm when he gets home. He has only been taking oral anti-diabetics for two months and the dose was titrated upwards recently. He finds they give him diarrhoea, ‘tummy pain’ and sometimes put him off his food. He is wondering if there is anything else the doctor could prescribe.

Recommendation

Metformin works by reducing hepatic glucose production, which increases insulin sensitivity in skeletal muscle. This improves peripheral glucose uptake and delays glucose absorption in the gastrointestinal tract. Mr Johnson's dose should therefore be taken at main mealtimes to mirror endogenous insulin secretion. Taking metformin with food will also minimise the adverse effects Mr Johnson is experiencing.

For consideration by

GP/patient Mr Johnson should be encouraged to take his dose with food and informed about the benefits and mechanism of the drug. He should report symptoms to his GP if they continue. One option could be to switch to a modified release preparation, which may help reduce side effects.

Issue

The patient confesses that he rarely uses the blood glucose testing strips because he doesn’t know when to do so,or how to interpret results. He was given a glucometer in clinic but has forgotten how to use it.

Recommendation

Glucose test strips are useful as the patient can monitor blood glucose levels after meals, fasting and exercise. This is particularly useful for patients who drive a lot, like Mr Johnson.

For consideration by

Patient A patient who is treated with metformin alone does not need to test blood glucose very frequently – approximately once or twice a week. In type 2 diabetes, blood glucose values should be 4-7 mmol/l before meals and less than 8.5 mmol/l two hours after meals. Mr Johnson needs to make sure he is testing his blood glucose levels at least weekly and shown how to use his glucose meter.

Issue

When asked about his lifestyle, Mr Johnson says that he doesn’t smoke but enjoys a few drinks at the weekend. He admits his diet could be improved – he is a fan of fast food and enjoys Sunday roasts. He is not very active these days and experiences back pain from time to time. He sometimes uses his wife’s ibuprofen and asks if that is OK.

Recommendation

Antidiabetic medicines are prescribed only as an adjunct to lifestyle change in early type 2 diabetes. By eating healthily, losing weight and exercising regularly, Mr Johnson may be able to keep his blood glucose at a safe and healthy level and avoid the need for additional antidiabetic medicines and insulin. Furthermore, healthy blood pressure and lipid levels are just as important as glucose control. Mr Johnson can continue to drink alcohol, as long as he stays within the recommended amounts (limit of two to three units per day for women and three to four units per day for men). Alcohol can cause hypoglycaemia and weight gain when used excessively. With a BMI of 29kg/m2, Mr Johnson is overweight but not obese, and should be trying to increase his exercise levels, especially as his occupation is quite sedentary. NSAIDs are not recommended in hypertension. However using the lowest dose for shortest period is generally considered safe. Paracetamol is also effective used in combination. It is recommended to separate ibuprofen dose from morning aspirin by two hours to avoid risk of gastrointestinal side effects.

For consideration by

Patient Mr Johnson should eat more fruit and vegetables, increase fibre and reduce fat (especially saturated fat), and only eat foods high in sugar/salt very sparingly. He should drink in moderation and try to increase his physical activity with exercises such as cycling, fast walking or aerobics. He should use ibuprofen only when required. If this is becoming regular, he should inform his GP who will prescribe a better alternative.

Issue

Mr Johnson wonders if there is any precaution to be taken when driving with diabetes.

Recommendation

Drivers of cars, lorries of buses, who are not taking insulin or medicines which can cause hypoglycaemia, must only inform the DVLA of their condition if they develop any complications that could affect their ability to drive safely. Complications include hypoglycaemia. Mr Johnson must monitor his blood glucose regularly and at times relevant to driving. He must also attend a medical/diabetic review regularly.

For consideration by

Patient Use blood glucose test strips to monitor glucose levels especially when driving for a living.

 

Sarah McBride is a locum pharmacist based in London

3 Comments

David Gay, Academic pharmacist

Your information about the DVLA is incorrect. The DVLA state that bus drivers with diabetes who are treated with sulphonylureas or glinides must inform them using form VDIAB1SG (available on the DVLA website). They go on to state: 'To meet the current Group 2 (lorry & bus) standards of medical fitness to drive, an applicant or licence holder who has diabetes treated with a Sulphonylurea or Glinide must check their blood glucose (sugar)level at least twice daily and at times relevant to driving. He/she must also keep a supply of fast acting carbohydrate, such as a glucose drink or sweets, within easy reach in the vehicle'.

Janet Fray, Community pharmacist

Although metformin does not cause hypoglycaemia he may get low glucose levels if he takes it and skips meals or does not have a regular eating pattern which could be the case since he is a bus driver. We could advise about eating habits and the risk of low glucose levels. It would also be appropriate to ensure he knows what hypoglycaemia is what are the symptoms and what he must do. Mr johnson may also benefit from a structured education programme such as DESMOND. Also there is a drug interaction between amlodipine and Simvastatin, there is an increased risk of statin side-effects with this combination. The recommended daily dose of Simvastatin should not exceed 20mg when co-administered with amlodipine, GP needs to be contacted.

David Moore, Locum pharmacist

Funnily enough, I'm a 64 year old bus driver! But pharmacist first. Might be worth telling this chap that if he's prescribed insulin, he can say goodbye to his bus driver's licence. Might concentrate his mind a bit.

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