Diabetes Medicines
Current Medicines
- Metformin 1 g tablet (controlled release), 2 tablets nocte.
- Rosuvastatin 10 mg tablets, 1 tablet daily.
- Perindopril arginine 5 mg tablets, 1 tablet daily.
Steve, a 45 year old man, presents for his regular prescriptions. Steve has been a patient of your practice for a while but hasn’t been in for some time. He works as a travel agent, has a supportive partner and two young children.
Steve’s history includes type 2 diabetes, hypertension and dyslipidemia. He’s overweight and is a former smoker. He regularly drinks alcohol and has no allergies.
You note that Steve’s family history indicates his father died of a myocardial infarction aged 54 years, and his mother has diabetes and renal failure.
On examination, Steve appears overweight. He is 178cm tall and weighs 93kg, with a BMI of 29.4. His BP is 145/89mmHg.
In talking to Steve, he explains that while he’s been taking his medicines regularly as prescribed. He has been struggling with diet and exercise. While he’d like to lose weight, he hasn’t had any success.
You provide Steve with his prescriptions and ask him to undergo some testing including HbA1C, electrolytes with eGFR, lipids and urine ACR. He makes an appointment for the following week.
You email Steve a link to the MAIA patient brochure
Next week, Steve attends his appointment. His record includes the following results:
- HbA1C 61 mmol/mol (7.7%)
- Lipids:
- Total cholesterol 3.6
- Triglycerides 2.4
- HDL cholesterol 1.1
- LDL cholesterol 2.3
- Urine ACR 1.8
- eGFR 88 ml/min/1.73m2
Steve’s current management isn’t achieving his agreed glycaemic target of HbA1C less than 48 mmol/mol (6.5%).
Activity 1
Even modest weight loss (5-10%) can help improve glycaemic control. Steve is overweight and expresses challenges with diet and weight loss.
Using a team care arrangement, what types of referrals could you make to allied health professionals to help support Steve?
Steve is currently taking controlled release Metformin 2 g daily, which is the maximum recommended dose for the controlled release formulation and suitable for his level of renal function.
Activity 2
Which of the following medicines is most appropriate to add to Steve’s existing regimen:
a) Semaglutide SC 0.25 mg once a week
b) Gliclazide PO 80 mg daily
c) Dapagliflozin PO 10 mg daily
d) Alogliptin PO 25 mg daily
An SGLT2 inhibitor is the most appropriate medicine to add to Steve’s existing regimen because it will reduce his cardiovascular risk, have reno-protective effects, and is affordable when prescribed through the PBS.
Activity 3
You consult the pbs.gov.au to review the PBS criteria. Which of the following options is most appropriate choice for Dapagliflozin 10 mg tablets?
a) Authority Required (STREAMLINED) 15311
b) Authority Required (STREAMLINED) 7528
c) Authority Required (STREAMLINED) 15047
d) Authority Required (STREAMLINED) 13230
e) Authority Required (STREAMLINED) 15265
f) Authority Required (STREAMLINED) 15051
g) Authority Required (STREAMLINED) 14471
When prescribing, its important to select the correct PBS streamlined authority code. This helps to make the medicine affordable for the patient.
SGLT2 inhibitors like dapagliflozin work by reducing glucose reabsorption in the kidney, and increasing the excretion of glucose into the urine.
Activity 4
Which of the following counselling points are important to explain to Steve when providing the dapagliflozin prescription (select all that apply):
- This medicine can make you thirsty and dehydrated. Make sure you drink enough water.
- This medicine must be taken on an empty stomach, at lease one hour before food or two hours after food.
- This medicine increases the risk of genital infections like thrush. Maintain good hygiene and seek medical help immediately if you notice any signs of infection.
- This medicine will cause your urine to test positive for glucose.
CPD - Review your own performance
To claim up to 2.5 hours of Reviewing Performance (0.5 hours per patient), please complete the following activity after reading the educational materials:
Find up to five of your patients with a diagnosis of type 2 diabetes and CVD or CKD. For each patient, review their record for their most recent HbA1C, prescribed diabetes medicines, and Medicines Review (see data collection template below).
Actions you could consider from the results of your mini-audit:
- If there is a diagnosis of heart failure or CKD, consider prescribing an SGLT2-inhibitor for management of these conditions.
- If the patient is not currently at their HbA1C target, review their prescribed medicines and consider escalation of therapy. Consider their comorbidities and the potential benefit of SGLT2-i or GLP1-A.
- If there has been no medicines review (MBS items 900, 903, 245 and 249) within the past 12 months, consider referring for an HMR or RMMR.
Note: to be eligible to claim 2.5 hours of Measuring Outcomes you must review a minimum of five patients.
Current Medicines
- Metformin 1 g tablet (controlled release), 2 tablets nocte.
- Rosuvastatin 10 mg tablets, 1 tablet daily.
- Perindopril arginine 5 mg tablets, 1 tablet daily.