According to the BNF, and the latest NICE guidelines (2009), should we change Miss HH’s therapy? What is your suggestion?

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

NICE Bites – Management of stable angina, UKMI, September 2011

BACKGROUND READING

Stable angina – Clinical features and diagnosis. Clinical Pharmacist, January 2012

Stable angina – Management. Clinical Pharmacist, January 2012

WORKSHOP EXERCISE

Fill in the empty boxes in the diagram of the renin-angiotensin system below.

ANSWER ALL THESE QUESTIONS USE THE READING LIST IN PREVIOUS PAGE TO HELP ANSWER THESE QUESTIONS IN DETAIL

Mr KK, a 61 year old Caucasian secondary school teacher, has recently been diagnosed with hypertension. His recent blood pressure reading was 165/100mmHg.

He feels generally well but has been under a great deal of stress at work recently. He has no past medical history. His older brother has hypertension and type II

diabetes and his father died aged 52 following a myocardial infarction. He has no other medical problems. He smokes 15 cigarettes a day and weighs about 100kg.

He doesn’t think that he has hypertension as he has had only 2 high readings but he is to have 24 hour blood pressure (BP) monitoring next week. He has also had blood

tests to check his blood sugar, cholesterol, renal function and liver function. He has read about white coat hypertension in the newspaper but was not sure what this

means.

 

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