PREPARED BY: MUHAMMAD ARIFF B. MAHDZUB BACHELOR MEDICINE AND SURGERY (MBBS) UNIVERSITY COLLEGE SHAHPUTRA, KUANTAN

1. Hypoglycemia & Management of Diabetes
in CKD Stage V
PROBLEM BASED LEARNING (PBL)
PREPARED BY: MUHAMMAD ARIFF B. MAHDZUB
BACHELOR MEDICINE AND SURGERY (MBBS)
UNIVERSITY COLLEGE SHAHPUTRA, KUANTAN

2. Patient’s Demographics
Name
Ward
DOA
Weight
Race
Gender
Age
RN
LT
Female
Chinese
50kg
10 June 2013
7C, Bed E18
90 years old
5798

3. Chief Complaint
Unresponsive, found by family members.
+ Heavy sweating, cold extremities, nausea,
dizziness, chest discomfort, palpitation
No vomiting, headache, URTI or UTI
symptoms, fever

4. History of Present Illness
• Poor oral intake
• Due to toothache for the past 2 days,
throbbing in nature
• Despite that, patient still continue metformin
and actrapid injections.

5. Past Medical History
• Diabetes Mellitus
• Hypertension under KK Bkt Sekilau
• Ischemic Heart Disease
• ? Diastolic Dysfunction - under cardio (EF = 72%,
good LV function)

6. Past Medication History
• T. Hydrochlorothiazide 50mg od
• T. Ticlopidine 250mg bd
• T. Spironolactone 12.5mg od
• T. Bisoprolol 1.25mg od
• T. Omeprazole 40mg od
• T. Perindopril 4mg od
• T. Metformin 500mg bd
• S/C Actrapid 6 units bd

7. Review of System
• BP : 119/52
• PR : 72
• RR : 20 breaths per min
• T : 37°C
• Dxt : 1.2 mmol/L

8. Social/Family History
• Married
• Lives with grandchildren.
• Does not smoke, imbibe alcohol or abuse
drugs.

9. • Hypoglycemia secondary to
toothache and poor oral intake
• Underlying hypertension, diabetes
mellitus, IHD
• Stage V CKD
• CAP
Diagnosis

10. Vital Sign

11. Temperature

12. Lab Investigation and Findings
Parameter Normal range D1 D2
10/6
TWBC 4-11 x10/L 10.99
Hb 13-17 g/100ml 11.6
Platelet 150-400 x 10/L 169
FBC
Lipid
Profile
Parameter Normal range D3
12/6
LDL-C < 2.5 mmol/L 3.44
HDL-C >1.1 mmol/L 0.98
TG <1.7mmol/L 0.67

13. Lab Investigation and Findings
Parameter Normal
range
D1
10/6
Urea 3.2-7.3 29.8
Na 136-146 133
K 3.5-5.1 3.9
Cl 98-106 101
SCr 59-104 206
Crcl 105-150 12.6
BUSE/
Renal
Profile

14. Dextrose Chart
Dextrose 50%
50ml + 1 pint
D5

15. Ward Medications
Antibiotics Date
Start
Date
Stop
Indication
IV Augmentin 1.2g stat & TDS
(not served)
10/6 10/6
Suspected CAPT. Azithromycin 500mg stat &
OD
(not served)
10/6 10/6

16. Ward Medications
Other Medications Date
Start
Date
Stop
Indication
T. Ticlopidine 250mg bd (not
served)
10/6 10/6 IHD
T. Spironolactone 12.5mg od 10/6 10/6
Hypertension
T. Hydrochlorothiazide 50mg od 10/6 10/6
T. Perindopril 4mg od 10/6 -
IV Frusemide 40mg bd 10/6 -
T. Bisoprolol 1.25mg od 10/6 - IHD, HF
T. Omeprazole 40mg od 10/6 - Stress ulcer prophylaxis
T. Bromhexine 8mg tds 10/6 Cough
T. Paracetamol 1g prn 11/6 Pain
IV Metoclopramide 10mg prn 11/6 Nausea

17. Ward Medications
Other Medications Date Start Date Stop Indication
S/C Actrapid 6 units tds 11/6 13/6
DMS/C Insulatard 6 units ON 11/6 13/6
T. Gliclazide 40mg bd 13/6

18. Pharmaceutical Care Issues
Diabetes in CKD
Hypoglycemia

19. Diabetes in CKD

20. Description Management Plan
Definition:
Diabetes - a state of
chronic
hyperglycaemia
caused by insulin
insufficiency or
resistance. Is a
leading cause of
CKD, which occurs
d/t augmentation of
ECM.
Sign & symptoms:
•Polydipsia
•Polyuria
•Polyphagia
•Blurred vision
•Weight loss
•Hyperglycaemia
•Nocturia
•Malaise/fatigue
•Persistent
albuminuria
•Decline in GFR
•Elevated arterial bp
Special considerations in the CKD Population
Management
Metformin was witheld. Actrapid and insulatard was
initiated on 11/6 and was switched to gliclazide 40mg bd
on 13/6 after dental procedure on patient’s request.
Comment
Management of DM
was appropriate.
Although the
Malaysian CPG (2009)
recommends to avoid
gliclazide in patients
with CrCl < 30ml/min,
the KDOQI Diabetes
Guidelines (2012)
recommends gliclazide
as it does not have
active metabolites and
do not inc the risk of
hypo in patients.
However, management
of comorbidities such
as hyperlipidaemia is
inadequate (refer to
DRP)
Monitor
•Dxt
(CPG: Management of chronic obstructive pulmonary disease, Nov 2009, Ministry of Health of Malaysia)

21. Special Considerations in CKD
Patients1,2
• Higher risk of hypoglycemia (see next PCI).
– Decreased excretion of insulin & OHAs
– Impaired renal gluconeogenesis with reduced kidney
mass.
• Fall in excretion of certain drugs (see DRP)
– Adjustment of doses
– Unsuitability of use of certain drugs
1. KDOQI Clinical Practice Guidelines for Diabetes and CKD: 2012 Update
2. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes in Chronic Kidney

22. Hypoglycemia

23. Hypoglycemia
A/E 8C
• IV Aminophylline 250mg
over 8H
• S/c Terbutaline 0.5mg
stat
• IV Hydrocortisone
200mg stat
• IV Hydrocortisone
100mg QID
• T. Theophylline SR
250mg BD
• T. Prednisolone 30mg
OD
• Neb combivent 4-6H
Description Management Plan
Definition:
Blood glucose level of less than
3.9 mmoml/L (American Diabetes
Association, European Medicines
Agency)
Causes:
OD, ill-timing or wrong type of
nsulin and OHA
↓ clearance of insulin or OHA d/t
enal impairment.
Reduced oral intake.
Improved insulin sensitivity.
Critical illness
Drugs, tumours & hormonal
deficiency.
Symptoms:
1)Autonomic – shaking, trembling,
weating, palpitations, paresthesia,
nxiety
2)Neuroglycopenic - cognitive
dysfunction, behavioural changes,
eizures, coma, death
Recommended management
Fully conscious patient: oral glucose, sucrose or sugar
containing fluids. Ensure adequate food intake to
prevent subsequent relapses.
When mental function is impaired: IV 50% dextrose
25-50ml until mental function recovers or blood
glucose = normal, then infusion of 5-10% dextrose or a
glucose drink if patient regains consciousness.
If hypoglycemia d/t long acting insulin or OHA, 5-10%
dextrose drip should be continued for 24-48 h.
Glucagon 1mg IM/SC can be given to treat severe
hypoglycemia when IV access is difficult.
Patient who remain unconscious after prolonged
hypoglycemia may need to be given treatment for
cerebral oedema with IV dexamethasone 4mg 6hrly or
IV mannitol.
Management
Patient administered 50ml of dextrose 50% in A&E
which was continued with 1 pint dextrose 5% in the 7C
Insulin and metformin was witheld.
Blood sugar = 19 mmol/L.
QID dxt was instituted.
Counselling was given to patient’s family by
pharmacist.
Comment:
Management was
appropriate.
Monitor:
-Dxt
(CPG: Management of chronic obstructive pulmonary disease, Nov 2009, Ministry of Health of Malaysia)

24. Drug Related Problems
Inappropriate use of drugs in CKD Stage V
Inadequate regimen of statins
Inappropriate discontinuation of ticlopidine for
tooth extraction

25. Issue Justification Suggestion
Patient has a CrCl of
12.8 upon admission.
Patient was previously
on T.
hydrochlorothiazide
50mg od & T.
metformin 500mg bd
and her old
medication was
planned to be
continued in the ward.
In addition patient
was also started on IV
Augmentin 1.2g tds
on 10/6.
According to Malaysian Clinical
Practice Guidelines for Diabetes
Mellitus (2009), metformin should not
be administered in patients with a CrCl
< 30ml/min. This is because it is
cleared by the kidneys and may build
up, leading to an increased risk of
lactic acidosis.
Thiazide diuretics are generally
relatively ineffective in patients with
GFR < 30ml/min. A loop diuretic is
preferred.
According to the National Antibiotic
Guideline 2008, Augmentin should be
reduced to a bd dosing.
Suggestion:
To ensure Metformin not restarted & to
start on insulin if indicated when
hypoglycemia resolved.
To off thiazide diuretics and replace with
loop diuretics if indicated.
To suggest a dose reduction of Augmentin
to 1.2g bd.
Outcome:
Metformin was not restarted. Pt started on
S/C Actrapid & Insulatard on the 11.6.
HCTZ was off and replaced with IV
frusemide.
Augmentin 1.2g tds was off on 10/6 (d/t
ruling out of CAP).
Inappropriate Drug Use in CKD Stage V

26. Issue Justification Suggestion
Patient has an
elevated LDL-C of
3.44 mmol/L (target
< 2.56 mmol/L) and
is not on any
therapy.
The use of statins are recommended in
patients with diabetes and hypertension
regardless of baseline cholesterol levels.
From the Pravastatin Pooling Project,
persons with diabetes and CKD had the
greatest risk of CVD death, MI or
revascularization procedures compared to
those with either condition alone or neither
condition. They also had the largest
absolute risk reduction with statin.
Suggestion:
Suggest to initiate T.
Simvastatin 20mg ON
(estimate 38%  in
LDL-C to reach 2.13
mmol/L)
Outcome:
To notify dr.
Simvastatin 40mg ON
has been initiated at
discharge.
Inadequate Regimen of Statins

27. Inappropriate Discontinuation of
Ticlopidine
Issue Justification Suggestion
Patient’s ticlopidine
was stopped in
view of her tooth
extraction.
Bleeding complications, while inconvenient, do
not carry the same risks as thromboembolic
complications. Patients are more at risk of
permanent disability or death if they stop
antiplatelet medication prior to a surgical
procedure than if they continue it. Published
reviews of available literature advise that
antiplatelet monotherapy should not be stopped
prior to dental surgical procedures. Post
operative bleeding following dental procedures
are minimal, easily visualized, has minor
consequences to the patient and can be
controlled using local hemostatic measures.
Suggestion:
To restart Ticlopidine
in the ward.
Outcome:
Ticlopidine was
restarted at discharge.
Patient did not suffer
any thromboembolic
complications or
bleeding.

28. Roles of DMTAC Pharmacist
• Patient insulin pen technique
 To evaluate and counsel patient to ensure that the correct
dose of insulin is administered.
• Hypoglycemia
 How to avoid hypoglycemia
 Recognition and management of hypoglycemia
 Sick day management
 SMBG

29. References
• United Kingdom National Health Service. Surgical management of the
primary care dental patient on antiplatelet medication. National
Electronic Library of Medicines. Accessed 13 June 2013.
• Jaffer AK. Perioperative management of warfarin and antiplatelet therapy.
Cleveland Clinic Journal of Medicine 2009;76(4):S37-44.
• Wan Mohamad WB, et al. Management of Type 2 Diabetes Mellitus. 4th
ed.
Malaysia: Ministry of Health Malaysia;2009.
• Clinical Practice Guidelines: Management of dyslipidaemia. Malaysia:
Ministry of Health Malaysia;2003.
• Smith SC, et al. AHA/ACC Guidelines for Secondary Prevention for Patients
With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update:
Endorsed by the National Heart, Lung, and Blood Institute. Circulation
2006;113;2363-2372.
• Hua HS, et al. Sarawak Handbook of Medical Emergencies. Third Edition

30. esophageal varicesTHANK YOU