PACE Case: Amputation Risk

A 62-year-old female PACE participant has a past medical history of Type 2 diabetes (T2DM), heart failure, urinary incontinence, hypercholesterolemia, obesity, and lower limb amputation. The participant was recently enrolled in a PACE facility and her prescriber requested that a polypharmacy review be conducted to reevaluate her medication regimen and reduce her medication risk score, which is currently 19 out of 50 (moderate).

Based on her past medical history, the CareKinesis pharmacist focused primarily on her diabetes medications, which includes:

  • Canagliflozin 100 mg, 1 tablet PO daily
  • Linagliptin 5 mg, 1 tablet PO daily
  • Humalog® Mix 75/25 KwikPen 25-75 units/mL, 40 units subcutaneously QAM and 30 units QPM

Participant Assessment:
At the time of review, the pharmacist found that the participant’s Hemoglobin A1C (HbA1C) was well above goal and her blood sugar levels were inconsistent and trending high. The pharmacist noted that canagliflozin has a black box warning because it is associated with a two-fold increase in lower limb amputations, especially in patients with a history of cardiovascular disease. Given the participant’s past history of lower limb amputation, heart failure, and hypercholesterolemia, the pharmacist determined that canagliflozin may be an inappropriate medication to treat her T2DM. Her insulin regimen was also failing to control her HbA1C and required changes.

Clinical Pharmacist Recommendation:
The clinical pharmacist alerted the physician of the participant’s risk for lower limb amputation while taking canagliflozin and recommended discontinuation. Additionally, the pharmacist advised changing the Humalog® Mix to a long-acting insulin such as Basaglar. By making these changes, the PACE clinical team can reduce the participant’s risk of future amputations and provide better blood glucose control. Switching to a long-acting insulin reduces the number of injections per day, potentially improving patient adherence. Upon the pharmacist communicating these recommendations, the prescriber immediately made the proposed changes.

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