Test yourself and your team with this scenario based on pharmacy practice

Leyton Miller is 64-year-old man with a recent diagnosis of diabetes. Pharmacist Ellen Rogers recruits Leyton to the new medicine service because metformin has been added to his repeat prescription. His PMR shows he takes:

● Metformin 500mg (starting today)

● Simvastatin 40mg

● Ramipril 10mg

● Warfarin 6mg daily

● Bisoprolol 10mg

Leyton has been trying to control his diabetes by diet, without much success. He asks Ellen about increasing his exercise. "I like to go for long walks at the weekend. I used to walk miles until I had the operation on my back and then I was laid up with a couple of clots in my legs, which is why I have to take the warfarin for the rest of my life. I feel fine now, though, and the docs at the hospital have given me the all clear.

"However, now my diabetes is getting worse, it seems, and I've decided action is called for. I'm going to cut down my eating. They say fasting is good for you. That's what's worked for me before, just stop eating, but I know if I could get walking again that would really speed things up. Is it OK?"

What questions should Ellen ask Leyton?

Ellen first needs to check that Leyton hasn't been told not to exercise. In most cases the benefits of physical activity far outweigh any risks. Leyton's history suggests DVTs, resulting in long-term warfarin therapy. Most people with long-term conditions are able to exercise. Sometimes, if the person has an unstable heart condition or a severe musculoskeletal problem, activity may be contraindicated but in most cases there is a form of activity suitable for everyone. People with a medical condition should always check with their clinician before commencing any exercise routine.

Can he increase his physical activity and is walking his best option?

Walking is excellent form of physical activity, suitable for people of all ages. It can be done in a range of intensities, to suit all abilities. It can be incorporated into daily living, for example, walking to the shops or to work.

Adults (aged 19 to 64 years) are advised to undertake at least 30 minutes of moderate intensity exercise on most days of the week. Moderate intensity is defined as leaving the person slightly warm, with a slightly raised heart beat and a little out of breath and brisk walking is a great example. Thirty minutes of moderate activity, five times a week has been shown to bring cardiovascular benefit. For Leyton, physical activity has the potential to help lower his blood pressure and blood glucose and can also help weight management alongside dietary measures.

What other advice can Ellen give him?

Leyton has clearly walked before. Adherence to an exercise programme is greatly enhanced if the individual finds the activity enjoyable. A social element to the activity can also be beneficial, helping to maintain motivation. In Leyton's case it would be a sensible precaution not to go out alone initially anyway, so that he has a helping hand should he get into difficulties. Leyton's previous experience of ‘walking miles' may be detrimental if he is inclined to overdo it. This might put him at more risk of injury and Ellen should speak to him about building his activity up gradually. He can also be advised about making sure he is adequately hydrated before, during and after walks.

Moderate exercise should not affect Leyton's warfarin levels. People taking warfarin are advised to avoid high contact sports where there is a greater likelihood of bruising and bleeding. However his suggested crash diet could cause changes to his INR and he should be advised to make gradual changes to his diet and advise the person who monitors his warfarin that he is introducing lifestyle changes.

Further reading

UK Physical Activity Guidelines

If you identify a gap in your knowledge, you might want to consider making a CPD entry.

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