Question

Mr. T. G. is a 74 year old admitted to the ED for complaints of a severe headache and slowly healing wound on his right foot.. You are evaluating his medications and note that he is taking medications for following conditions:

• Type 2 diabetes mellitus
• Hypertension
• Hypercholesteremia
• Osteoarthritis

1. Identify common medications that are prescribed for these conditions; then check for the BEERS criteria, identify drug-to-drug interaction potential, and discuss polypharmacy concerns. Develop a teaching plan for this patient.

Answer 1

For type 2 diabetes Metformin will be the 1st choice of drug followed by glp1 analogue like exenatide . Metformin produces adverse effects like vit b12 deficiency, lactic acidosis and bloating and anorexia.  

• Metformin is contraindicated in renal insufficiency patients , those who have hypotension , heart failure, hepatic disease.  
• Drugs like cimetidine , furosemide may compete with metformin and enhance its toxicity .
• Drugs to be avoided according to beers criteria is sulfonylureas like chlorpropamide and glyburidewhich due to long t1/2 can cause hypoglycemia in adults .

Hypertension :  

Diuretics and calcium channel blockers are prescribed for older patients to treat hypertension. Ace inhibitors are 2nd choice of drug

• Diuretics like thiazides can precipitate diabetes hence given with caution
• Indomethacin and other nsaids dimnish the action of thiazides
• Probenecid decrease diuretic action of it .
• High ceiling diuretics and aminoglycosides are both ototoxic and nephrotoxic hence should not be given .
• Thus for traeting hypertension combination of 2 drugs should be given
• Ace inhibitors with spironolactone may precipitate hyperkalemia hence these two combinations are avoided .
• Cal channel blockers like verapamil and diltiazem are first line drug in hypertension, verapamil should not be given with beta blockers because it causes conduction defects , both cal channel blockers also cause digoxin toxicity .

Hypercholesterolemia

Statins are the 1st choice of drug for treating hypercholesterolemia. Incidence of mi , strole , peripheral arterial disease , cardiovascular diseases are reduced due to this .

Liver damage due to rise in serum transaminase is seen , myopathy is also common when gemfibrozil, ketoconazole cyclosporine is given , statin dose is reduced when given with fibrates , a 10 % risk in diabetes patients is noted so dose must be adjusted .

Osteoarthritis:

NSAIDS is the preffered drug for osteoarthritis,, but should be given with caution .

Acetaminophen is the preffered choice of drug for patients not tolerable to aspirin and other nsaids

Ketoprofen , ibuprofen, diclofenac are preferred nsaids

Amlodipine a calcium channel blocker and celecoxib an nsaid can be given incase of hypertension and osteoarthritis.

Corticosteroids should not be preffered since diabetes may be exacerbated.

THUS THE PATIENT IS ADVISED TO FOLLOW A PROPER MEDICATION WHICH decreases the side effeccts and toxicity due to drug interaction. Diet also plays an essential role in controlling these morbidities  , physical activity is a must in these patients.  

Preffered choice of drug in this patient is metformin , verapamil, stains and acetaminophen which will help to increase the survival and reduce the complications and drug interaction.