Ayub Teaching Hospital, Abbottabad

INPATIENT DRUG CHART

Patient Identification & Demographics

Patient Name: aslam khan

Phone / Mobile: xx yy zz
C N I C: 13501 4473975-5
Gender: Male
Age: 42 years
Home Address: Mansehra
Date: 11/12/2016
Bed No: MAW-29
Consultant: Dr. irfan

Diagnosis: Diabetes mellitus, Poor glycemic control

Chief Complaints:
 Fever for 1 week
 Rigors and chills for 1 week
 Productive cough for 1 week
 Swollen right foot

History of Present Illness:

Patient is known diabetic and hypertensive for last 10 years. He is presented
with fever accompanied with rigors and chills for last 1 week. She has productive
cough along with-it sputum is scanty.

Past Medical History: Patient is diabetic and hypertensive.

Family History: Family has history of DM for 10 years and HTN for 3 years

Personal History:
 Sleep: Normal
 Appetite: Normal
 Bowel: Normal

Social History: Socioeconomic status is satisfactory

Allergies (Non-drug): No known allergies

Drug allergy: NKDA
MEDICATION HISTORY

Purpos Status/
Duratio Undesire Complian
Drugs e of Reason for Response
n d effect ce
use d/c
Amlodipi Few Discontinu Satisfacto
HTN Non Good
ne 5mg years ed ry
Not
Few
Insulin DM Still in use satisfactor Non Poor
months
y
Few Discontinu Satisfacto
Amaryl DM Non Good
years ed ry

PHYSICAL EXAMINATION

General:
Vital Signs
BP: 125/90 mmhg RR: Unknown
PR: 100/min TEMP: 99oF
L- E+ T- J- A+ C- K-
Systemic:
Cardiovascular: S1 + S2 + 0
Gastrointestinal: Soft, Non-tender
Respiratory: B/L clear
Nervous system: Alert

OTHER TESTS
DATE WISE RESULT
NORMAL
TEST 12- 11- 10- 09- 08- 07- 06- 05-
RANGE
11 11 11 11 11 11 11 11
70-150 - - - - -
RBS - - -
mg/dL
70-100 - - - - -
FBS 82.1 62.9 58.7
mg/dL

Sliding Scale Insulin Protocol

Blood Glucose Human Insulin, Additional
Level (mg/dl) IU Action
0-80 0 1 Ampule of D50
81-100 0 No action
101-151 0 No action
151-200 2 No action
201-250 4 No action
251-300 6 No action
310-350 8 No action
361-400 10 No action
>401 12 Call physician
 CHEMISTRY-1
Patient Name: Shakir Azeem
Address: Peshawar
Test Result Reference Test
Values
Glucose F mmol/l 4.0 – 6.0 Protein
Glucose R mmol/l up to 10.0 Albumin
Urea mmol/l 1.7-8.3 Globulin
Creatinine mmol/l M 53-97 T. Bilirubin
F 44-90

Total Bilirubin mg/dl 0.1-1.0 T. Bilirubin

ALT/GPT U/L 10-50 Enzymes

Alkaline U/L 35-104 Enzyme

Phosphatase

Uric acid 69 mmol/l M 202-416 Bilirubin(D)

F 140-340
Calcium mmol/l 2.12-2.75 Bilirubin (ID)
Phosphorus mmol/l 0.87- 1.45 ALK Phosphates
Sodium mmol/l 1.35-143 ALT/GPT
Potassium mmol/l 3.5-5.5 GOT
Cholesterol mmol/l 2.5-6.4 LDH
Triglyceride mmol/l 0.4-2.0 CPK
HDL Chol mmol/l 0.83-2.5 Amylase
LDL Chol mmol/l Up to 4.0 Acid Phos
Urine volume /24 hr.
Urine protein /24hr

DIAGNOSIS:

Diabetes mellitus, Right diabetic foot, Poor glycemic control

TREATMENT AT HOSPITAL

Drug (Glycerine Date: 11/11 12/11 13/11

suppository)
Dose Route
3mg P/O
Freq Sign
OD
Date: 10/11/17
Drug (Duphalac syrup)
Dose Route 10am 10am
30mg P/0 02pm 02pm
Freq Sign 08pm 08pm
TDS
Date: 10/11/17
Drug (Tab. Duragesic)
Dose Route 10 am 10am 10am
50 mcg/mL P/O
Freq Sign
BD
Date: 10/11/17
Drug (Insulin (R) )
Dose Route 8am 8am
20-M S/C 8 pm 8 pm 8am
Freq Sign 8 pm
DTS
Date: 10/11/17
Drug (Co-valtic) 8 am 8 am 8 am
Dose Route
25mg P/O
Freq Sign
OD
Date: 10/11/17
Drug (Tab.Sitamet) 8 am 8 am
8 pm 8 pm
Dose Route
50/1000
Freq Sign
BD
Date: 10/11/17
Drug (Tab. Adalat) 10 am
Dose Route
60mg P/O
Freq Sign
OD
Date: 10/11/17
Drug (Tab. Concor) 10 am
Dose Route
5mg P/O
Freq Sign
OD
Date: 10/11/17
Drug (Tab. Qalsan D) 8 am
Dose Route
P/O
Freq Sign
OD
Date: 10/11/17
Drug (Tab. Citanew) 8 am
Dose Route
5mg P/O
Freq Sign
OD
Date: 10/11/17
Drug (One-Alpha Capsule) 8 am
Dose Route
0.5microgm P/O
Freq Sign
OD
Date: 10/11/17
Drug (Inj. Adronil) 11:6 am
Dose Route
3mg P/O
Freq Sign

Date: 10/11/17

CASE ANALYSIS & DISCUSSION

SIGNIFICANT FINDINGS OF MEDICATION HISTORY

Number of Drugs: 13
Name of Drugs
 Amlodipine
 Insulin
 Glimepiride
Allergy: No known allergy
Response: Insulin response was not satisfactory
Compliance: Poor
ADR’s: No ADRs were observed
Clinical Importance
Patients medication history shows poor compliance related to insulin use which
resulted in uncontrolled glucose level and other diabetes complications.

MEDICATION USED IN THE HOSPITAL

Number of drugs : 12

DRUG NO 1:
Insulin Lispro: 50%, Insulin Lispro DRUG NO 2:
protamine:50% Glycerine suppository
Therapeutic Class : Therapeutic Class :
Anti-diabetic hyperosmoticlaxatives
Indications : Indications :
Diabetes mellitus Constipation
Dosage : Dosage :
Should be adjusted according to patient Should be adjusted according to patient
requrement,by S/C injection 15 min requrement,3mg used.
before or after meal.

DRUG NO 3: Duragesic
Duphalac syrup Therapeutic Class :
Therapeutic Class : An opioid pain medication. An opioid
Hyperosmotic laxatives is sometimes called a narcotic.
Indications : Indications :
Constipation Duragesic patches are a strong
Dosage : prescription pain medicine. The
Should be adjusted according to patient patches are used to treat moderate to
requrement, 30mg used in current case. severe chronic pain in opioid-tolerant
patients, severe enough to require
daily, around-the-clock, long-term
opioid treatment.
Dosage :
50 mcg/mL
DRUG NO 4:

DRUG NO 5: Dosage :
Co-valtic 160mg/12.5mg/25mg. 25mg is used in
Therapeutic Class : this case.
Anti-hypertensive Ingredients: Valsartan
Indications : 160mg,Hydrochlorothiazide 12.5mg
Hypertension,Heart Failure,Post-
Myocardial Infarction.

DRUG NO 6: Indications :
Sitamet Diabetes mellitus
Therapeutic Class : Dosage :
Anti-diabetic
Should be adjusted according to patient
requrement,500mg is used.

DRUG NO 7: Adalat CC is used to treat hypertension

Adalat
Therapeutic Class :
Adalat CC (nifedipine) belongs to a
group of drugs called calcium channel
blockers. It works by relaxing the
muscles of your heart and blood
vessels.
Indications :
(high blood pressure) or angina (chest
pain).
Dosage :
Should be adjusted according to patient
requrement,60mg is used.The usual
maintenance dose is 30 mg to 60 mg
once daily.

DRUG NO 8: Concor 5 and 10 mg: High blood

Concor pressure (hypertension). Coronary
Therapeutic Class : heart disease [(CHD); angina pectoris].
Bisoprolol, the active ingredient of Dosage :
Concor, is a β1-selective adrenoceptor- 5 and 10 mg.5mg is used in current
blocking agent. case.
Indications :

DRUG NO 9: Dosage:
Qalsan d Tab Adults & Children:
Drug Category: As a supplement to diet 1 tab daily.
Calcium supplement with vitamin D The dosage may be increased when
Generic Name: there is higher demand for calcium e.g.
Calcium carbonate and Vitamin D pregnancy, lactation etc.
Contents: Contra-indications:
Chewable Tabs: Cacium carbonate Hypercalcaemia, hypercalciuria, severe
USP 1250mg (500mg elemental renal failure, renal calculi,
calcium) Vitamin D 125 I.u sugar free galactosaemia.
(contains aspartame). Precautions:
Indications: In renal impairment, electrolyte imbal-
Raised calcium requirements, e.g. ance, monitor blood and urinary
during pregnancy, lactation, children calcium levels.
and adolescents at times of rapid Interactions:
growth. Inadequate intake of calcium Cardiac glycosides, thia-zides,
in diet. Osteoporosis. As a supplement tetracyclines.
to vit D in treatment of rickets and Adverse effects: Diarrhoea.
osteomalacia.

DRUG NO 10: Escitalopram is an antidepressant

Citanew belonging to a group of drugs called
Therapeutic Class : selective serotonin reuptake inhibitors
(SSRIs). It affects chemicals in the
brain that may be unbalanced in people
with depression or anxiety.
Indications :
It is used in treating depression and
panic disorder with or without
agoraphobia (fear of places/situations
that cause anxiety).
Dosage :
5 mg; 10 mg; 20 mg; 5 mg/5 mL.5mg
is used in current case.

DRUG NO 11:
One-alpha capsules
Therapeutic Class :
Vitamin D and analogues
Indications :
One-Alpha is indicated in all conditions where there is a disturbance of calcium
metabolism due to impaired 1-α hydroxylation such as when there is reduced renal
function. The main indications are:Renal osteodystrophy, Hyperparathyroidism (with
bone disease), Hypoparathyroidism, Neonatal hypocalcaemia, Nutritional and
malabsorptive rickets and osteomalacia, Pseudo-deficiency (D-dependent) rickets and
osteomalacia, Hypophosphataemic vitamin D resistant rickets and osteomalacia.
Dosage :
Each capsule contains 1 microgram of alfacalcidol or 0.25 micrograms of alfacalcidol
or 0.5 micrograms of alfacalcidol(used in current case).
Contraindications:
Hypersensitivity to the active substance or to any of the excipients. Hypercalcaemia,
metastatic calcification.

DRUG NO 12:
Adronil :
Therapeutic Class :
Ibandronate is a bisphosphonate medicine that alters bone formation and breakdown
in the body. This can slow bone loss and may help prevent bone fractures.
Indications :
Ibandronate is used to treat or prevent osteoporosis in women after menopause.
Dosage :
Should be adjusted according to patient requrement, 30mg is used.
 SELECTION OF THERAPY/ DRUG(S):
The following medications were prescribed for following reasons:
 Insulin 70/30 & Sitagliptin + Metformin: Diabetes
 Glycerin suppository + lactulose: Laxatives
 Nifedipine, Valsartan & Bisoprolol: Hypertension
 Paracetamol + Thioridazine + Caffeine: Anti inflammatory
 Escitalopram: Antidepressant
 Alfacalcidol & calcium carbonate + Vitamin D3: Dietary supplement

SUB-THERAPEUTIC DOSE: NILL

OVER DOSAGE: NILL
DRUG USE WITHOUT INDICATIONS: NILL
UNTREATED CONDITIONS: NILL
IMPROPER DRUG SELECTION: NILL
FAILURE TO RECEIVE DRUGS: NILL
ADRs:
DRUG INTERACTIONS:
DRUG-DRUG SEVERITY CLINICAL OUTCOME
INTERACTION
Thioridazine - Major Coadministration with inhibitors of
Escitalopram CYP450 2D6 may increase the
plasma concentrations of thioridazine,
associated with dose-related
prolongation of the QT interval, thus
elevated plasma levels of the drug
may potentiate the risk of ventricular
arrhythmias such as ventricular
tachycardia as well as cardiac arrest
and sudden death.
Insulin - Metformin Moderate Coadministration of metformin with
an insulin secretagogue (e.g.,
sulfonylurea, meglitinide) or insulin
may potentiate the risk of
hypoglycemia. Although metformin
alone generally does not cause
hypoglycemia under normal
circumstances of use, the added
therapeutic effect when combined
with other antidiabetic agents may
result in hypoglycemia.  palpitation, tachycardia).
Insulin - Sitagliptin Moderate Coadministration of a dipeptidyl
peptidase-4 inhibitor with an insulin
CLINICAL MANAGEMENT
The use of thioridazine with drugs that
inhibit CYP450 2D6 is considered
contraindicated. Depending on the
elimination half-life of these drugs, a
considerable waiting period may be
appropriate following their
discontinuation before thioridazine is
initiated.
A lower dosage of the insulin
secretagogue or insulin may be
required when used with metformin.
Blood glucose should be closely
monitored, and patients should be
educated on the potential signs and
symptoms of hypoglycemia (e.g.,
headache, dizziness, drowsiness,
nervousness, confusion, tremor,
hunger, weakness, perspiration,
A lower dosage of the insulin
secretagogue or insulin may be
 secretagogue (e.g., sulfonylurea,
meglitinide) or insulin may potentiate
the risk of hypoglycemia.
Thioridazine - Moderate The efficacy of insulin and other
Sitagliptin antidiabetic agents may be diminished
by certain drugs, including atypical
antipsychotics, corticosteroids,
diuretics, estrogens, gonadotropin-
releasing hormone agonists, human
growth hormone, phenothiazines,
etc. These drugs may interfere with
blood glucose control because they
can cause hyperglycemia, glucose
intolerance, new-onset diabetes
mellitus, and/or exacerbation of
preexisting diabetes.
Calcium carbonate - Moderate Products containing aluminum,
Ibandronate calcium, magnesium and other
polyvalent cations such as antacids or
vitamin with mineral supplements are
likely to interfere with the
gastrointestinal absorption of oral
bisphosphonates.
Insulin - Escitalopram Moderate The hypoglycemic effect of insulin
may be potentiated by certain drugs,
including ACE, (ARBs), 4-
aminoquinolines, amylin analogs,
anabolic steroids, fibrates,(MAOIs,
including linezolid), salicylates,
selective serotonin reuptake inhibitors
(SSRIs), sulfonamides, Clinical
hypoglycemia has been reported
during use of some of these agents
alone or with insulin and/or insulin
secretagogues. Use of SSRIs has also
been associated with loss of
awareness of hypoglycemia in
isolated cases.
Glycerin - Moderate Bowel cleansing as well as overuse of
Escitalopram certain laxatives may cause
electrolyte loss and increase the risk
of torsade de pointes ventricular
arrhythmia in patients treated with
drugs that prolong the QT interval.
Bisoprolol - Valsartan Moderate In the Valsartan Heart Failure Trial,
the combination of valsartan with a
beta-blocker and an ACE inhibitor
was associated with unfavorable
outcomes on morbidity and mortality
in heart failure patients.
required when used in combination
with a dipeptidyl peptidase-4 inhibitor.
Caution is advised when drugs that can
interfere with glucose metabolism are
prescribed to patients with diabetes.
Close clinical monitoring of glycemic
control is recommended following
initiation or discontinuation of these
drugs, and the dosages of concomitant
antidiabetic agents adjusted as
necessary
Antacids or other oral medications
containing aluminum, calcium,
magnesium and other polyvalent
cations should be administered at least
30 minutes after the bisphosphonate
dose.
Close monitoring for the development
of hypoglycemia is recommended if
these drugs are coadministered with
insulin, particularly in patients with
advanced age and/or renal impairment.
The insulin dosage may require
adjustment if an interaction is
suspected.
Patients treated with drugs that prolong
the QT interval should exercise caution
when self-medicating with laxatives.
The recommended dosage and duration
of use should not be exceeded.
The manufacturer recommends that the
triple combination of valsartan with a
beta-blocker and an ACE inhibitor be
avoided in heart failure patients.
Nifedipine - Moderate Nifedipine may increase plasma If nifedipine and metformin must be
Metformin concentrations of metformin by used together, cautious titration of
increasing the extent of absorption. metformin dosage is recommended.
Increased metformin levels may Increased metformin levels may
increase the risk of lactic acidosis. increase the risk of lactic acidosis.
Patients should be advised to monitor
their blood glucose
Nifedipine - Minor Coadministration with inhibitors of
Escitalopram CYP450 3A4 is not expected to
significantly affect the
pharmacokinetics of citalopram or
escitalopram, both of which are
partially metabolized by the
isoenzyme

PATIENT EDUCATION & COUNSELING

Patient’s attendant was educated about diabetes and. He was educated about diabetes
control and relevant monitory test and medications including proper usage of insulin.

OUTCOME OF MEDICATION THERAPY

Patient’s glucose level was controlled, and patient recovered.