Stuart Shortland B.Pharm (Syd) GradDipHlthSc (Herbal Med)
HMR Accredited Pharmacist & Herbalist
Dear Dr Blank, Thank you for referring Mr John Blank, an 84 year old man with a history of diabetes, GORD, hypertension, IHD, tinnitus and vertigo, for a home medication review. I visited him at his home on Friday 6th August. He is currently taking the following medications. Brand Name
Key Report Findings
• High triglycerides and high-normal HBA1c may benefit from an increase in
diabetic control by increasing the metformin dose to 1 gram daily. This dose is well within acceptable limits of renal function.
• Please review use of frusemide. Consider replacing with a thiazide diuretic
such as hydrochlorothiazide or replacing Coversyl with Coversyl Plus to improve control of blood pressure.
• Consider the addition of vitamin b12 injections, as both metformin and
rabeprazole are known to decrease absorption of vitamin b12 and possibly lead
Stuart Shortland B.Pharm (Syd) GradDipHlthSc (Herbal Med)
HMR Accredited Pharmacist & Herbalist
to macrocytic anaemia. Mr Blank’s MCV levels are on the high side of normal and possibly indicative of macrocytic anaemia.
• Compliance and diet are generally good. The lifestyle advice I gave is listed
Please find the full report below. If you have any points you would like to discuss, please don’t hesitate to contact me. The recommendations in this report have been based on the information provided to me and are for your consideration. It is realised that there may be sound clinical reasons not to adopt the above recommendations. Regards, Stuart Shortland
Stuart Shortland B.Pharm (Syd) GradDipHlthSc (Herbal Med)
HMR Accredited Pharmacist & Herbalist
Glucose control is sub optimal as recent
It is recommended to increase the dose of
results have varied between 7.4 and 7.2.
The HBA1c target in diabetics is <7%.
be well within acceptable limits of renal
decreasing the HBA1c by 1% results in a reduction of 14% in the incidence of MI and all cause mortality (eTG Complete 2010). Mr Blank’s creatinine clearance (CrCL)
75kg as 52mL/min. For a renal clearance of between 30-60mL/min the maximum recommended dose is 1 gram/day (AMH 2010). Triglycerides and Cholesterol
Mr Blank’s last triglyceride and total
It is recommended to increase the dose of
with his risk factors of age >55 and past
If this is unsuccessful consider the use of
a fibrate such as gemfibrozil or fish oil 1
gram 6 times daily to lower triglycerides
It has been shown that an increase in glycaemic control will result in lower TG levels (eTG) and hence a lower total cholesterol as Tc = LDL + HDL +TG/2.19 (Heart UK 2007). Hypertension
patients with a CrCL of between 30-60 is
2.5mg daily (AMH 2010). Considering the target BP of a person
12.5mg daily or replace current Coversyl
Thiazide diuretics are longer acting and
failure. Furthermore, some of its listed
side effects include: vertigo and tinnitus,
considered preferable to loop diuretics in
this circumstance (Mathews & Johnson
Stuart Shortland B.Pharm (Syd) GradDipHlthSc (Herbal Med)
HMR Accredited Pharmacist & Herbalist
Metformin is known to decrease absorption of vitamin B12 (AMH 2010). Rabebprazole is also known to impair absorption of vitamin B12 (AMH 2010) Tinnitus and Ear Problems
Lasix is not indicated for the treatment of
Mr Blank reports ear pain and itchy ears. Review cause of ear pain/itch. I advised For the pain he takes ibuprofen and for
He may be reporting akathisia, which is a
restlessness that is worse at night that
2010). As stemetil is required to treat Mr
Blank’s vertigo no change is recommended.
Blister packing of his medications should
be considered as an aid to compliance but
According to our records the last time he
organisation of medication at home is ok.
Please supply him with a new script so he
Mr Blank’s glyceryl trinitrate spray was
per week. This level of exercise has been
diabetics and will aid weight loss (Penny
Mr Blank’s diet seems balanced and not
I reinforced the importance of a healthy
Stuart Shortland B.Pharm (Syd) GradDipHlthSc (Herbal Med)
HMR Accredited Pharmacist & Herbalist
creatinine ratio of 14.1 indicates he has
microalbuminuria. Furthermore, the ratio antagonist. The combination of AT2 has increased over the last 3 years
additional protection against proteinuria (Mogensen et al. 2000). If condition worsens consider referral to a dietician for a low protein diet. Protein levels in the diet of 0.75-1g/day/kg of lean body mass are considered appropriate (Mathews & Johnson 2008).
References
Australian Medicines Handbook Pty Ltd 2010, Australian Medicines Handbook,
Heart UK, 2007, ‘Calculating Cholesterol’, Retrieved from
http://www.heartuk.org.uk/images/pdf/uploads/healthylivingpdfs/HUKcfs_E_Freidewald_Method.pdf
Johnson, D.W. & Mathew, T. 2008, ‘How to treat: Proteinuria’, Australian Doctor, 1
Mogensen, C.E., Neldam, S., Tikkanen, I., Oren, S., Viskoper, R., Watts, R.W. &
Cooper, M.E. 2000, ‘Randomised controlled trial of dual blockage of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: The candesartan and lisinopril microalbuminuria (CALM) study’, British Medical Journal, vol. 321, no. 7274, pp. 1440-1444.
Penny, B. 2007, ‘Prescribing exercise for diabetes’, Australian Prescriber, vol. 30, no.
Reutens, A.T., Shaw, J.E. 2008, ‘Oral antidiabetic therapy for people with type 2
diabetes etg exenatide Incretin enhancers and mimetics’, Australian Prescriber, Retrieved from http://www.australianprescriber.com/magazine/31/4/104/8/
Therapeutic Guidelines Limited, 2010 (Updated June 2008), ‘Diabetes Complications:
Large vessel disease’, eTG Complete[Internet], Retrieved from http://www.tg.org.au
Therapeutic Guidelines Limited, 2010, ‘Dyslipidaemia: predominant elevation of
fasting triglyceride’, eTG Complete[Internet], Retrieved from http://www.tg.org.au
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