PACE Case: Diabetes Management

A 67-year-old female participant with a history of type 2 diabetes, hypertension, osteoarthritis, and gastroesophageal reflux disease (GERD) is newly enrolled in PACE. Upon initial examination, the participant complains of arthritic pain. Additionally, she reveals that she has been having increased episodes of hypoglycemia since being diagnosed with type 2 diabetes a few years ago, despite being on a regimented meal and exercise plan. The physician is curious as to why her blood glucose numbers keep fluctuating.

The patient’s medication regimen includes:

  • Metformin 500 mg QD
  • Glyburide 5 mg BID
  • Lantus 5 units daily
  • Celebrex 200 mg BID PRN

Upon contacting the PACE center’s CareKinesis pharmacist, the physician is questioned on the patient’s intake of Celebrex. The physician states that she presumed the patient was taking it on a scheduled basis due to her arthritic pain.

Upon a review of the patient’s record in EireneRx, the pharmacist noticed that the Medication Risk Management Matrix revealed an interaction between Celebrex and glyburide, which both go through the CYP2C9 pathway. Celebrex is a stronger substrate and competes with Glyburide, therefore increasing the concentration of glyburide and accounting for the increased bouts of hypoglycemia.

The CareKinesis pharmacist informed the physician of the drug interactions and recommended that the participant use Tylenol for pain control, as needed, instead of Celebrex. Because glyburide is on the BEERS list, an additional recommendation was made to switch to glimepiride, 2 mg daily. The physician agreed to both changes. Upon follow-up a few weeks later, the physician reported that the participant was satisfied with the level of pain control with Tylenol. The participant also complained less about her bouts of hypoglycemia.

During the follow-up, the pharmacist questioned the need for Lantus, since the patient was only on 5 units daily and both oral agents were low doses. The physician agreed to the pharmacist’s recommendation of removing insulin and increasing metformin to 500 mg twice daily.

Due to the participant’s compliance with her medications and diet/exercise plan, glimepiride was subsequently removed from her medication regimen. Her type 2 diabetes is controlled on metformin alone, as opposed to the three medications she was on when she entered PACE.