A 64-year-old patient referred for management of diabetes weighed 256 lb
(she was 134 lb when she got married 40 years ago); was 60” tall; and had
a BMI of 50. Her diabetes was poorly controlled with random blood glucose in
the clinic of 291 mg/mL. Her most recent HbA1c was 11.9%. In addition to her
diabetes, she claimed a diagnosis of hypothyroidism, fibromyalgia and
Those were the least of her troubles!
Before I saw her in consultation she was evaluated over the years by a
primary care physician and five consultants. Between them, they had prescribed
16 different medications adding up to 25 tablets daily. In addition, she took
three calcium tablets and two vitamin D capsules. Two other prescription
medications accounted for five tablets a day as needed, and she used three
different eye drop medications (each eye), totaling 10 drops a day. To round
out her medications, she used a nasal spray daily, one multivitamin capsule and
took one calcitriol tablet a week. She also used steroid cream used daily.
Several of these prescribed medications were for important clinical issues
(hypertension, hypercholesterolemia, mild renal impairment) that she did not
note on her intake form.
Polypharmacy at its worst!
To my recollection, this is the most medicated patient I have seen for
quite some time. After that clinic day was over, I took the time to go through
her list of prescribed medications to find out how frequently each one was
accompanied by a note of caution about interaction with others on her list. I
gave up after five of them were to be used with caution in conjunction with
others on her list.
I am not certain my recommendation did not add to her woes, as I
discontinued the oral medication for diabetes and replaced it with pre-meal
rapid acting insulin and bed-time long-acting insulin.
Diabetes is associated with a number of other medical conditions, each
of which appropriately requires intervention, as is the case with this patient.
Where we all need some help is the development of an algorithm to prioritize
each additional therapy. But whose job is that? There are published guidelines
for management of diabetes, hyperlipidemia, hypertension, you name it …
and few, if any of us, can claim sufficient expertise to put these into
clinical perspective in individual patients like this patient.
From time to time I will get a call from a pharmacist letting me know
that my new prescription clashes with a drug the patient is already taking. If
possible we work on an alternative but that is no easy task.
As always, I welcome your feedback and advice.