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Stuart Shortland B.Pharm (Syd) GradDipHlthSc (Herbal Med)
HMR Accredited Pharmacist & Herbalist Dear Dr Blank, Thank you for referring Mr John Blank, an 84 year old man with a history of diabetes, GORD, hypertension, IHD, tinnitus and vertigo, for a home medication review. I visited him at his home on Friday 6th August. He is currently taking the following medications. Brand Name Key Report Findings
• High triglycerides and high-normal HBA1c may benefit from an increase in diabetic control by increasing the metformin dose to 1 gram daily. This dose is well within acceptable limits of renal function. • Please review use of frusemide. Consider replacing with a thiazide diuretic such as hydrochlorothiazide or replacing Coversyl with Coversyl Plus to improve control of blood pressure. • Consider the addition of vitamin b12 injections, as both metformin and rabeprazole are known to decrease absorption of vitamin b12 and possibly lead Stuart Shortland B.Pharm (Syd) GradDipHlthSc (Herbal Med)
HMR Accredited Pharmacist & Herbalist to macrocytic anaemia. Mr Blank’s MCV levels are on the high side of normal and possibly indicative of macrocytic anaemia. • Compliance and diet are generally good. The lifestyle advice I gave is listed Please find the full report below. If you have any points you would like to discuss, please don’t hesitate to contact me. The recommendations in this report have been based on the information provided to me and are for your consideration. It is realised that there may be sound clinical reasons not to adopt the above recommendations. Regards, Stuart Shortland Stuart Shortland B.Pharm (Syd) GradDipHlthSc (Herbal Med)
HMR Accredited Pharmacist & Herbalist Glucose control is sub optimal as recent It is recommended to increase the dose of results have varied between 7.4 and 7.2. The HBA1c target in diabetics is <7%. be well within acceptable limits of renal decreasing the HBA1c by 1% results in a reduction of 14% in the incidence of MI and all cause mortality (eTG Complete 2010). Mr Blank’s creatinine clearance (CrCL) 75kg as 52mL/min. For a renal clearance of between 30-60mL/min the maximum recommended dose is 1 gram/day (AMH 2010). Triglycerides and Cholesterol Mr Blank’s last triglyceride and total It is recommended to increase the dose of with his risk factors of age >55 and past If this is unsuccessful consider the use of a fibrate such as gemfibrozil or fish oil 1 gram 6 times daily to lower triglycerides It has been shown that an increase in glycaemic control will result in lower TG levels (eTG) and hence a lower total cholesterol as Tc = LDL + HDL +TG/2.19 (Heart UK 2007). Hypertension patients with a CrCL of between 30-60 is 2.5mg daily (AMH 2010). Considering the target BP of a person 12.5mg daily or replace current Coversyl Thiazide diuretics are longer acting and failure. Furthermore, some of its listed side effects include: vertigo and tinnitus, considered preferable to loop diuretics in this circumstance (Mathews & Johnson Stuart Shortland B.Pharm (Syd) GradDipHlthSc (Herbal Med)
HMR Accredited Pharmacist & Herbalist Metformin is known to decrease absorption of vitamin B12 (AMH 2010). Rabebprazole is also known to impair absorption of vitamin B12 (AMH 2010) Tinnitus and Ear Problems Lasix is not indicated for the treatment of Mr Blank reports ear pain and itchy ears. Review cause of ear pain/itch. I advised For the pain he takes ibuprofen and for He may be reporting akathisia, which is a restlessness that is worse at night that 2010). As stemetil is required to treat Mr Blank’s vertigo no change is recommended. Blister packing of his medications should be considered as an aid to compliance but According to our records the last time he organisation of medication at home is ok. Please supply him with a new script so he Mr Blank’s glyceryl trinitrate spray was per week. This level of exercise has been diabetics and will aid weight loss (Penny Mr Blank’s diet seems balanced and not I reinforced the importance of a healthy Stuart Shortland B.Pharm (Syd) GradDipHlthSc (Herbal Med)
HMR Accredited Pharmacist & Herbalist creatinine ratio of 14.1 indicates he has microalbuminuria. Furthermore, the ratio antagonist. The combination of AT2 has increased over the last 3 years additional protection against proteinuria (Mogensen et al. 2000). If condition worsens consider referral to a dietician for a low protein diet. Protein levels in the diet of 0.75-1g/day/kg of lean body mass are considered appropriate (Mathews & Johnson 2008). References
Australian Medicines Handbook Pty Ltd 2010, Australian Medicines Handbook, Heart UK, 2007, ‘Calculating Cholesterol’, Retrieved from http://www.heartuk.org.uk/images/pdf/uploads/healthylivingpdfs/HUKcfs_E_Freidewald_Method.pdf Johnson, D.W. & Mathew, T. 2008, ‘How to treat: Proteinuria’, Australian Doctor, 1 Mogensen, C.E., Neldam, S., Tikkanen, I., Oren, S., Viskoper, R., Watts, R.W. & Cooper, M.E. 2000, ‘Randomised controlled trial of dual blockage of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: The candesartan and lisinopril microalbuminuria (CALM) study’, British Medical Journal, vol. 321, no. 7274, pp. 1440-1444. Penny, B. 2007, ‘Prescribing exercise for diabetes’, Australian Prescriber, vol. 30, no. Reutens, A.T., Shaw, J.E. 2008, ‘Oral antidiabetic therapy for people with type 2 diabetes etg exenatide Incretin enhancers and mimetics’, Australian Prescriber, Retrieved from http://www.australianprescriber.com/magazine/31/4/104/8/ Therapeutic Guidelines Limited, 2010 (Updated June 2008), ‘Diabetes Complications: Large vessel disease’, eTG Complete[Internet], Retrieved from http://www.tg.org.au Therapeutic Guidelines Limited, 2010, ‘Dyslipidaemia: predominant elevation of fasting triglyceride’, eTG Complete[Internet], Retrieved from http://www.tg.org.au

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