Clinical reasoning
A patient with diabetes came in to refill prescriptions for a full year. When I reviewed the prescriptions and his recent test results, I noticed his HbA1C was very high and his kidney function was declining quickly. During a medication review, he told me he had stopped taking metformin because his creatinine clearance was below 60 ml/min, but no alternative treatment was arranged to control his blood sugar.
I explained to him, citing Diabetes Canada guidelines, that metformin could still be used safely at his dose, and that uncontrolled diabetes could cause serious complications. I checked to see if he had any signs of lactic acidosis, and he did not. Then, I faxed the doctor with this information, including suggestions to consider newer medications that could help protect his kidneys, like Jardiance or Ozempic.
The doctor responded gratefully and prescribed Jardiance. We set up three-month monitoring for his blood sugar and kidney function and referred the patient to a dietician for nutritional guidance. I also encouraged him to use a continuous glucose monitor to better understand how lifestyle and medication affected his blood sugar.
After three months, his blood glucose was improving, and his kidney function had stabilized. I reminded him about regular eye exams and the importance of promptly addressing any injuries to avoid serious complications.
Because of a pharmacist, something important happened.
