MTAC Diabetes

Diabetes MTAC?
An ambulatory care service conducted by pharmacists in collaboration with physicians with the aim of helping diabetic patients improve their medication adherence level and glycemic control.

Objectives:
Max. the benefits of medication therapy in diabetic pt. Reduce adverse effects and complications. Assist clinicians in the management of pt placed on anti-diabetic therapy. Educate pt. Reduce emergency room visits

Case presentation
Pt name: PPM 78 y.o. Female Chinese BW= +/-80kg Admitted to Merak on 14/9/11 NKDA

Chief compliant: Abdominal distention/pain Vomiting

History of present illness: h/o extended right hemicolectomy (2008) for hepatic flexure adenocarcinoma Completed 6 cycle of chemo.

Past Medical History: DM HPT IHD Social/Family history: Stay w/ her daughter. No smoking No alcohol

Past medication history: T. Metoprolol 50 mg BD T. Lovastatin 20 mg ON T. Aspirin 150 mg OD T. Irbersartan 150 mg OD T. Gliclazide 40 mg BD

Day/Date Urea

14/9 15.4

15/9

Na
K SrCr ClCr RBS BP Temp PR

137
4.3 188 26.4 5.8 8.1 166/76 37 86

Current medications:
Drug IV Vancomycin 1g OD SC Clexane 40 mg OD T. Metoprolo 50 mg BD T. Lovastatin 20 mg ON T. Carvedilol 6.25 mg BD T. Gliclazide 80 mg BD T. Aspirin 300 mg OD T. Aspirin 150 mg OD Date start 15/9 15/9 15/9 15/9 15/9 15/9 15/9 15/9 Cancelled 15/9 Date stop

Cap. Tramadol 50 mg TDS

15/9

Date 15/9

PCI

Recomendations

Outcome To prevent over hypotensive actions. Prevent overdose.

Polypharmacy: Advise to stop T. Metoprolol 50 mg BD vs T. Carvedilol 6.25 mg BD Prescribing error: T. Aspirin 300 mg OD BMI= 80 1.62 =31.25 Obese pt. Gliclazide may promote weight gain. Change to the old dose which is 150 mg OD T. Metformin?? ClCr = 26.4 ml/min In CPG-metformin cntraindicated if Clcr below 60 ml/min. Continue gliclazide in case benefit outweight risk.

15/9

14/9

References:
Protocol Medication Therapy Adherence Clinic: Diabetes, First Edition 2010. Clinical Practice Guideline Diabetes.