Type 2 diabetes mellitus with severe frailty

Case summary

Background (age, sex, occupation, baseline function)

71 years old female, with very severe frailty
Lives with husband who is her carer

History of presentation/reason for review

Home visit by frailty multidisciplinary team (MDT), after recent fall and hospitalisation

Current medical history and relevant co-morbidities

Malignant neoplasm of cervix – 8 months ago
Type 2 diabetes mellitus (T2DM) – 8 years ago
Ischaemic heart disease (IHD) – 9 years ago
- angina pectoris – 9 years ago
- acute myocardial infarction and coronary artery bypass graft (CABG) – 7 years ago
Essential hypertension – 11 years ago
Chronic obstructive pulmonary disease (COPD) – 12 years ago
Depressive episode, unspecified – 16 years ago
Hypothyroidism – 25 years ago

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies or adverse drug reactions: nil

Currently prescribed:

Ascorbic acid 500mg tablets: two tablets morning and night
Blood glucose testing strips: use as directed
Carbocisteine 375mg capsules: two capsules three times a day
Doxazosin 4mg tablet: one tablet daily
Ferrous fumarate 210mg tablets: one tablet twice a day
Folic acid 5mg tablets: one tablet in the morning
Furosemide 40mg tablets: two tablets twice a day
Glyceryl trinitrate 400micrograms/dose pump sublingual spray: one to two puffs under the tongue if required for chest pain
Insulin lispro 100units/ml solution for injection 3ml pre-filled pen: to be injected twice a day
Insulin glargine 300units/ml solution for injection 1.5ml pre-filled pen: to be injected as directed by diabetes specialist nurse
Insulin needles: to be used as directed
Lactulose 3.1-3.7g/5ml oral solution: 10ml twice a day
Lancets 0.2mm/33 gauge: use as directed
Levothyroxine sodium 100microgram tablets: one tablet once daily
Liraglutide 6mg/ml solution for injection 3ml pre-filled: 1.2mg once daily
Metformin 500mg tablets: two tabs twice daily before breakfast and evening meal
Mirtazapine 45mg tablets: one tablet at night
Oxycodone 5mg modified-release tablets: one tablet twice a day
Pregabalin 25mg capsules: one capsule twice a day
Salbutamol 100micrograms/dose inhaler CFC free: one or two puffs up to four times daily as required
Salbutamol 2.5mg/2.5ml nebuliser liquid unit dose vials: use one nebule when required as directed by respiratory clinic
Solifenacin 5mg tablets: one tablet in the morning
Trelegy Ellipta® 92mcg/55mcg/222mcg per dose device: one inhalation once daily
Venlafaxine 75mg tablets: two tablets in the morning and one at night

Over the counter medicines: nil

Lifestyle and current function

Clinical Frailty Score (Rockwood) 8 (very severely frail)
Recent fall and hospital admission, has walking frame but does not use it
Ex-smoker
On long-term oxygen therapy (LTOT)

“What matters to me” (ideas, concerns and expectations of treatment)

Reducing risk of falls “I don’t want to be in hospital”
“Can I take less tablets? Do I need them all?”

Observations, examinations and results

Note: local laboratory reference ranges may vary

Weight 104kg, Height 161cm, BMI 40.1kg/m²
BP 123/72mmHg
eGFR 60ml/min/1.73m², calculated creatinine clearance 42ml/min
Urine albumin 3mg/ml, urine creatinine 9.1mmol/l (9 - 18mmol/L), ACR 0.3mg/mmol (in diabetes ACR>3.5mg/mmol in women is considered clinically significant)
HbA1c 57mmol/mol (7.4%)
Cholesterol 6.3mmol/L (<5.0mmol/L)
LFTs within normal range
TSH within normal range
FBC within normal range
Folate >20nanograms/mL (2.5-20nanograms/mL)

Most recent relevant consultations

Recent fall and hospitalisation

7 steps: Person specific issues to address

1. Aims: What matters to the individual about their condition(s)?

Review diagnoses and consider:

Therapeutic objectives of drug therapy
Management of existing health problems
Prevention of future health issues, including lifestyle advice

Ask person to complete PROMs (Questions to answer before medicines review) before their review

Person specific issues to address

Reducing risk of falls “I don’t want to be in hospital”
“Can I take less tablets? Do I need them all?”

2. Need: Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice)

Drugs that have essential replacement functions (e.g. levothyroxine)
Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address

Essential – levothyroxine, Note: insulin for symptom control, not essential in T2DM

3. Does the individual take unnecessary drug therapy?

Identify and review the continued need for drugs

what is medication for?
with temporary indications
with higher than usual maintenance doses
with limited benefit/evidence for use
with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address

FBC and folate in range: stop ferrous fumarate and folic acid
Hypertension: BP well controlled, severe frailty, history of falls – stop doxazosin
Furosemide: 80mg twice daily for fluid overload, oedema controlled, reduce dose
Solifenacin: still incontinent, risk of anticholinergic effects, trial stop
Ascorbic acid: no longer indicated and recently omitted with no difference in symptoms – stop

4. Effectiveness: Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

to achieve symptom control
to achieve biochemical/clinical targets
to prevent disease progression/exacerbation
is there a more appropriate medication to achieve goals?

Person specific issues to address

T2DM: HbA1c 57– Consider individual treatment in relation to frailty and therapeutic aims. Receives short and long-acting insulin, metformin and GLP-1RA (liraglutide): reduce metformin (renal impairment); discuss with diabetes specialist nurse to review liraglutide, rationalise insulins
Analgesia: oxycodone MR used regularly, pregabalin not indicated for cancer pain – started for sciatica, now resolved, trial stopping
COPD: poor inspiratory flow and on LTOT. Has both pressurised MDI and dry powder inhaler. Check inhaler technique and if required change Trelegy® to Trixeo® with spacer

5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?

Identify individual safety risks by checking for

appropriate individual targets e.g. HbA1c, BP
drug-disease interactions
drug-drug interactions (see ADR table)
monitoring mechanisms for high-risk drugs
risk of accidental overdosing

Identify adverse drug effects by checking for

specific symptoms/laboratory markers (e.g. hypokalaemia)
cumulative adverse drug effects (see ADR table)
drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness

Person specific issues to address

Solifenacin: anticholinergic side effects
Metformin: eGFR 44ml/min, therefore, reduce dose
Oxycodone MR: side effect constipation (Bristol stool chart 2). Essential for cancer, therefore, optimise therapy and change when required lactulose to regular macrogol sachets
Mental health – takes both venlafaxine and mirtazapine - increased risk of serotonin syndrome – under care of mental health team but lost contact, and will follow up for review

Medication Sick Day Guidance given for furosemide and metformin

6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?

Identify unnecessarily costly drug therapy by

considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

Inhaler use
Single use plastics
Medicines waste
- over-ordering
- disposal
Water pollution

Person specific issues to address

Carbocisteine - could be switched to acetylcysteine effervescent tablets which will reduce tablet burden
Advised to dispose of medicines through the community pharmacy
Advised to only order what is needed, do not stockpile medicines

7. Person-centredness: Is the person willing and able to take drug therapy as intended?

Does the person understand the outcomes of the review?

Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

is the medication in a form they can take?
is the dosing schedule convenient?
what assistance is needed?
are they able to take medicines as intended?

Agree and communicate plan

discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
include lifestyle and holistic management goals
inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete PROMs (Questions to answer after medicines review) after their review

Agreed plan

Stop ascorbic acid, doxazosin, ferrous fumarate, folic acid, pregabalin, solifenacin
Reduce furosemide, metformin
Change lactulose to macrogols, carbocisteine to acetylcysteine
Community pharmacy contacted regarding immediate changes
Follow-up with mental health team, diabetes specialist nurses

Key concepts in this case

Increasing frailty requiring de-escalation of diabetes and hypertension therapies
Opportunity for review of all medication, identifying:

what matters to the individual - reduced medication burden

unnecessary therapies

increased risk of adverse effects