Dina Cohen

RX # *- METFORMIN

Professor. Loveless

October 22, 2020

Introduction

A.B. is a 69-year-old, patient presents to the clinic with uncontrolled diabetes, a Hemoglobin A1C greater than 8. He was previously taking Glyburide but admitted stopping taking it since it was causing him to have periods of dizziness, sweating and agitation. He also states he was taking chromium Picolinate, Gymnema Sylvestre and a Pancreas Elixir for his diabetes but admits stopping to take these medications after seeing no results. A.B. has a history of hypertension and hyperlipidemia. He is currently taking Atorvastatin 10 mg daily for his elevated cholesterol. Patient is obese and gained 22 lb. in past year. Patient states his diet consists mostly of carbohydrates and pasta. Patient lacks education about proper glycemic control. A.B has stopped smoking for over 10 years. Patient has no past surgical history. Ever since A.B. retired he has been more physically active by playing golf once a week and gardening. Patients most recent vital signs are Temperature- 97.6 F, Blood pressure – 154/96 mmHg, heart rate- 88 beats per a minute, respirations- 20 per minute.

Metformin

Metformin is the first line medication for elderly patients with type 2 diabetes. This drug does not stimulate insulin secretion and has a low risk of causing hypoglycemia. Cardiovascular risks are reduced in patients taking metformin. Metformin can cause mild gastrointestinal intolerance like abdominal pain, diarrhea, nausea, vomiting, bloating and anorexia. Therefor when prescribing Metformin, it is recommended to titrate the dose till the target dose is reached to prevent gastrointestinal intolerance. Metformin has been shown to reduce A1C levels by 1% (Apovian, Okemah and O’Neil, 2018). The patient will be started on Metformin two tablet of 500 mg with breakfast and dinner for the first week. For week two Metformin will be titrated up to 750 mg. (1 pills for each dose) twice a days with breakfast and dinner. For week three the dose of metformin will be titrated up 1000 mg. twice a day with breakfast and dinner. Metformin is swallowed whole, it is never crushed or split. Metformin is always given with meals or after meals to prevent Gastrointestinal intolerance (GLUCOPHAGE® (metformin hydrochloride) Tablets, 2020).

Goals to Achieve Patients Hemoglobin A1C less than 7

A.B should make behavioral changes necessary for his health. The patient verbalizes all proper measures that was taught to him. The patient should be will pamphlet on how to properly control his Diabetes. A.B is ready to prepare his medication in a pill box and turn on a reminder to ensure that he does not forget a dose. The patient agrees to exercise three times a week with a friend or a family member. Also, A.B agrees to go to the nutritionist for a consult, so he can learn how to eat foods to help him with having adequate glucose control which should also help him lose weight. The patient should be recommended to follow up in 8 months. By having the patient follow these recommendations we can the patient reach his end goal.

Pharmacology/Mechanism of Action

Metformin is considered a biguanide that enhances glucose tolerance in people who have Diabetes Mellitus by decreasing the basal and postprandial plasma glucose. This medication lowers hepatic glucose production by lowering intestinal absorption of glucose and enhancing insulin sensitivity by raising peripheral glucose uptake and utilization. Patients taking Metformin will not develop hypoglycemic symptoms or hyperinsulinemia. When taking Metformin, the insulin secretion stays the same, while fasting insulin levels and daylong plasma insulin response will decrease. After taking Metformin it takes 7-8 hours to achieve maximum plasma metformin concentration. Metformin should be given right after the patients ate a meal to achieve therapeutic benefit. When a patient is on a low-fat or high-fat meal the systemic exposure increases by 38-73%. After taking the first dose of Metformin the volume of distribution would be an average of 654 358 L. Metformin barely bounds to plasma proteins. Many times, this medication divides into erythrocytes. The plasma concentrations of Metformin is 24-48 hours. The maximum metformin plasma levels do not go above 5µg/mL. Metabolism of Metformin is excreted through the urine by the kidneys and does not go through hepatic metabolism or biliary excretion. Studies on extended-release metformin tablets have not been conducted. The renal clearance of Metformin is 3.5 times more than creatinine clearance therefore, tubular secretion is of elimination. After the medication is administered ninety percent of the medication is eliminated through the renal route within the first day, and the plasma elimination half-life is around 6.2 hours. The elimination half-life is around 17.6 hours in the blood since the erythrocyte mass will be a part of the distribution. Metformin’s mean volume of distribution is between 63-276 liters. The plasma elimination half-life is between 2-6 hours (GLUCOPHAGE® (metformin hydrochloride) Tablets, 2020).

Side Effects

Metformin can cause hypoglycemia if given with other oral medication. It can also cause stomach pain, nausea, vomiting and diarrhea. Metformin can cause lactic acidosis, which can cause death (GLUCOPHAGE® (metformin hydrochloride) Tablets, 2020).

Conclusion

A.B. came to the diabetic clinic with uncontrolled diabetes and obesity. Patient was give medication to get his diabetes in control. Patient was also given recommendations to follow to lose weight. ICD-10-CM Diagnosis Code R73.9 Hyperglycemia, unspecified.

References:

Apovian, C., Okemah, J. and O’Neil, P., 2018. Body Weight Considerations in the Management of Type 2 Diabetes. Advances in Therapy, 36(1), pp.44-58.

2020. GLUCOPHAGE® (Metformin Hydrochloride) Tablets. [ebook] Available at: <https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020357s037s039,021202s021s023lbl.pdf> [Accessed 22 October 2020].

Brooklyn Urgent Care

Address: 1800 Ocean PKWY. Phone/Fax #- 718-***-****

BROOKLYN, NY, 10012

Prescriber: Dina Cohen

NPI #-100*******

DEA #- 30090078

Name: A.B

DOB: 11/21/1951

Address: 1901 Bay PKWY.

Brooklyn, NY, 10901

Rx Week 1: Metformin 500 mg. oral 2 times a day

Dispense: #14

Prescriber Signature: Dina Cohen

Date: 10/22/2020

Brooklyn Urgent Care

Address: 1800 Ocean PKWY. Phone/Fax #- 718-***-****

BROOKLYN, NY, 10012

Prescriber: Dina Cohen

NPI #-100*******

DEA #- 30090078

Name: A.B

DOB: 11/21/1951

Address: 1901 Bay PKWY.

Brooklyn, NY, 10901

Rx Week #2: Metformin 750 mg. oral 2 times a day

Each pill contains 500 mg.

Patient should be instructed to cut a pill in half so that dosing can be accurate.

Dispense:# 21 pills

Prescriber Signature: Dina Cohen

Date: 10/22/2020

Brooklyn Urgent Care

Address: 1800 Ocean PKWY. Phone/Fax #- 718-***-****

BROOKLYN, NY, 10012

Prescriber: Dina Cohen

NPI #-100*******

DEA #- 30090078

Name: A.B

DOB: 11/21/1951

Address: 1901 Bay PKWY.

Brooklyn, NY, 10901

Rx Week #3: Metformin 1000 mg. 2 tablets oral two times a day.

Dispense: #28 pills

Prescriber Signature: Dina Cohen

Date: 10/22/2020

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