According to the BNF, and the latest NICE guidelines (2009), should we change Miss HH’s therapy? What is your suggestion?
Wgt 80kg Temp. 37.1 degrees
Hgt 5’6’’ BP 147/85mmHg
a) Comment on Miss HH’s glucose and HbA1c in relation to NICE guidance.
You can use the 2112 rule to convert old HbA1c to new units and vice versa:
old to new: -2 x 11 -2;
new to old: +2 divided by 11 +2.
b) Work out Miss HH’s B.M.I. and ideal body weight. Are these relevant?
BMI = wt (kg) IBW= 50kg (men)/45.5kg (women)
Ht2(m2). + 2.3kg for each inch > 5 feet.
c) Comment on Miss HH’s creatinine and urea: use Cockcroft and Gault’s method to estimate her renal function.
8) According to the BNF, and the latest NICE guidelines (2009), should we change Miss HH’s therapy? What is your suggestion?
9) A nursing student comes to you and tells you Miss HH’s “BMs are 2.3” (Random peripheral blood glucose is 2.3 mmol/L). What are the symptoms of a hypoglycaemic
attack and how would you would treat it? Why do some patients not exhibit any symptoms?
10) Three months later, Miss HH is taking gliclazide 160mg BD but her blood sugar remains at least 11.5mmol/L most of the day. Three possible options exist other
than starting insulin. Which of the three possibilities below might or might not be suitable for Miss HH? Which would you support? Refer to the NICE algorithm.
a) Exenatide
b) sitagliptin
c) pioglitazone
11) After a further 6 months on pioglitazone 30mg daily and gliclazide 160mg BD, Miss HH’s HbA1c remains stubbornly high at 78mmol/mol in the diabetic clinic. The
doctor decides to stop her pioglitazone and start subcutaneous insulin therapy whilst continuing gliclazide. Describe 3 different kinds of insulin regime – suggest
preparations and doses. Which one would you recommend for Miss HH? Which regime best mimics the body’s natural insulin release?
12) Should Miss HH be started on aspirin or a statin? (Refer to the NICE Guidance 2009).
At home, complete the care plan for Miss HH at the point of hospital admission in Q7.
Pharmaceutical care plan for Miss HH DOB 1/6/1968 (on admission)
Problem Desired outcome Assessment Actions
Options Follow up/monitoring Counselling
DM2
HBA1c to 6.5%
No hypos (see below)
HBA1c and glucose uncontrolled on metformin 1g BD
? Compliance
Cr= 250 micromol/L
BMs/HbA1c in longer term
Push dietary advice
How to manage hypos
Risk of hypoglycaemic attacks
Want none None yet but risk if starts non-metformin based therapy
Cardiovascular risk
Reduce risk of CVD (CHD+stroke) plus PVD,CKD, retinopathy and nephropathy DM2 (Uncontrolled) BP, CBG (BM), lipids, HbA1c regularly
CKD Stop further deterioration, avoid ESRF>> Check chronic/acute Already lost 2/3 of GFR by age 65- bodes ill Needs tight BP (esp c ACE); tight sugar control
BP, Cr, urinary protein regularly,
VTE prophylaxis whilst in hospital
WORKSHOP TWO
MAJOR THEMES
HYPERTENSION
PRIMARY AND SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE
ISCHAEMIC HEART DISEASE
LEARNING OBJECTIVES
Following the workshop, directed and background reading, students should be able to describe/understand:
1) Basic principles and problems in the management of hypertension
2) The importance of considering concomitant illness in the selection of antihypertensive therapy
3) The concept of cardiovascular risk including primary and secondary prevention of cardiovascular disease.
4) Management of stable ischaemic heart disease
DIRECTED READING
BNF sections 2.5 Introductory pages
Stable angina. NICE Clinical Guideline CG126 2011- Quick reference guide
Management of hypertension in adults in primary care. NICE Clinical Guideline CG127 2011
MHRA and CHM. Aspirin: not licensed for primary prevention of thrombotic vascular disease. Drug Safety Update 2009;3(3):10-11.
NICE Bites – Hypertension, UKMI September 2011