PACE Case: Glycemic Control

A PACE program nurse practitioner approaches a CareKinesis clinical pharmacist for help with a participant’s anti-diabetic medication regimen. The participant is an 89-year-old female with a past medical history of chronic kidney disease (CKD) stage 4, hyperlipidemia, type 2 diabetes, hypertension, gastroesophageal reflux disease, and iron-deficiency anemia.

The only medication that the participant is using for diabetes is Novolog 4 units TID. Her self-measured non-fasting glucose readings are in the 300s, with a recent Hemoglobin A1c (HbA1c) level of 5.9%. The high blood glucose readings are contradictory to the HbA1c value that is within goal.

The pharmacist asks the nurse practitioner to recheck non-fasting glucose readings to see if the values recorded by the participant are accurate. Upon the nurse practitioner reporting that the values she recorded were similar, the pharmacist suggests rechecking the HgbA1c, which also remains consistent.

The pharmacist reexamines the participant’s labs and notices that her hemoglobin, which was 7.9 mg/dL upon first reading, drops to 5.1 mg/dL within a 10-day time period. The pharmacist alerts the nurse practitioner, who then admits the participant to the hospital.

While in the hospital, the participant is found to have upper gastrointestinal bleeding, diverticula, polyps, and hemorrhoids. Her stools are discolored, and the participant reports that the iron supplements she takes darkens her stool. The participant receives three units of packed red blood cells in the hospital and her hemoglobin increases to 8 mg/dL. The drop in hemoglobin is a result of a combination of her worsening CKD, which causes anemia, along with the internal bleed.

HgbA1c measures what percentage of hemoglobin is coated with sugar. If a participant has a bleed causing low hemoglobin, then there is less time for that blood cell to be exposed to glucose. When hemoglobin levels decrease, HgbA1c levels can decrease leading to a false representation of glycemic control. For someone with worsening CKD or anemia, HgbA1c can underestimate a person’s average glycemia.

The participant is eventually discharged from the hospital and the pharmacist worked with the nurse practitioner to modify the hospital’s anti-diabetic regimen. The participant is now using 8 units of Basaglar once daily, and four units of Humalog TID, and her fasting blood glucose levels are in the low 100s.

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