2015

DM MTAC TRAINING CASE PRESENTATION

Nurul Farhana Binti Ismail

Pegawai Farmasi U41
Hospital Sik

DEMOGRAPHIC DATA
Name

SHA

Age

34 years old

Gender

Female

Race

Malay

Weight

95 kg

Diagnosis

DM,HTN,IHD,Dyslipidemia

PAST MEDICAL HISTORY

Diabetes Mellitus Type 2
Retinopathy (severe NPDR, eye clinic hosp
kulim)

Proteinuria 24 hr urinary protein 4.8g/day

Hypertension
IHD with dilated cardiomyopathy

Angiogram on 3/6/15

Dyslipidemia

MEDICATION
PAST MEDICALHISTORY
HISTORY
Medication

Dose

Frequenc
y

Indication

S/C Mixtard

20 u

BD

DM

T. Metformin

500 mg

BD

DM

T. Bisoprolol

2.5 mg

OD

IHD/HPT

T. Frusemide

40 mg

OD

IHD/HPT

T. Diltiazem

30 mg

TDS

IHD/HPT

T. Ramipril

2.5 mg

OD

IHD/HPT

T. Atorvastatin

40 mg

ON

Dyslipidemia

T. Ferrous
fumarate

400 mg

OD

Anemia

T. Bco/Folate

I/I

OD

Vitamin deficiency

Morisky scale: 5.5 (poor adherence)

SOCIAL HISTORY
No drug abuse
No smoking
Non-Alcoholic

DRUG ALLERGY

NKDA

PHYSICAL PRAMETER/GLYCEMIC CONTROL

Parameter

Normal

4/8/14

20/1/15

BP (mmHg)

<130/80

138/78

146/88

FBS (mmol/L)

4.4-6.0

11.6

16.5

2HPP (mmol/L)

4.4-8.0

RBS (mmol/L)

<10.0

HbA1c (%)

<6.5

13.1

RBS (14/9/15) : 14.8 mmol/L

LIPID PROFILE
Parameter

Normal

26/4/15

15/6/15

25/8/15

3.5-5.7

7.4

6.1

5.6

TGL (mmol/L)

< 1.7

2.7

2.2

2.4

LDL (mmol/L)

< 2.6

4.9

3.6

HDL (mmol/L)

> 1.1

1.3

1.08

0.9

T. Chl
(mmol/L)

Significant Laboratory Findings

Renal Profile
Parameters

Normal Range

15/6/15

25/8/15

Na+

136-145 mmol/L

135

131

K+

3.5 4.5 mmol/L

5.5

4.6

SCr

57 130 umol/L

114

137

CrCl

60 -100 mL/min

92

76

Significant Laboratory Findings

Liver Function Test

Parameters

Normal Range

15/6/15

25/8/15

Albumin

35 52 g/L

34

29

T.Bilirubin

<30 umol/L

4.7

0.7

T.Protein

66-87 g/L

73

70

ALP

63-141 u/L

81

103

ALT

<32 u/L

14

14

Pharmaceutical Care
Intervention
Issue

Intervention

Outcome

Suggest to change
Patient cannot stick to
rigid meal time.
from
patient usually skip
premixed insulin to
meals
basal
due to hectic life, thus
bolus insulin
not
injecting insulin

Change to S/c Actrapid

10 U
TDS, S/c Gargine 24 U
ON

Newly started
Actrapid
insulin and Glargine
insulin

Counselled on the
dose and
frequency of insulin.
Encouraged SMBG

Patient understood

Patient has less

understanding on
diabetic
diet

Counselled on
diabetic diet,
emphasize on
carbohydrate
exchage

Patient understood

Patient has poor

Counselled on the

Patient understood

* Glargine reduces
incidence of hypo

NPH VS Glargine
Long acting insulin analogs have lower risk of

hypoglycemia than NPH human insulin in both Type 1

and Type 2 diabetes. [1]
Based on Cochrane review of RCTs in T2DM, compared
to NPH insulin, risk of hypo was 30% lower with insulin
glargine.
Glargine also improving glycaemic control in T1DM and
T2DM patient inadequately controlled by NPH, reduced
HbAIc by 0.38 % and 0.31% respectively. [2]
1 % reduction of HbA1c associate with 14% reduction of
MI and all cause mortality, 37% reduction of
microvascular complication, and 21% reduction of
overall diabetic complications significantly meaningful
[3]

REFERENCES
1. Monami M etc. Long acting insulin analogues vs NPH insulin for

type 2 diabetes mellitus. Cochrane Database Syst Review.

2008;81:184-189
2. Peter Sharplin etc. improved glycaemic control by switching
from insulin NPH to insulin Glargine: a retrospective study.2009
3. Stratton IM etc. Association of glycaemia with macrovascular
and microvascular complications of T2DM; prospective
observational study. BMJ 2000.
4. MOH CPG Management of Type 2 Diabetes Mellitus 4 th edition
2009