What to do With an A1C? and the Rest of the Story

What to do with an A1C ?  For the experienced clinician, this is a very simple question, but I occasional see orders for A1C’s at a rate more frequently than every three months.  Remember that it is basically an average blood sugar over a period of approximately three months.  This can vary a little bit, but thinking about this fact, what value would an A1C monthly provide?

If you ever seen an order for a monthly A1C or even more frequently than that, question it with boldness :)  I’ve seen a few recently where medication changes have been made and then two weeks or a month later an order for an A1C.  I suspect in the majority of cases I’ve come across, it is an oversight by the primary provider.  The only potential benefit you could get from checking it more frequently than every three months is to get an overall trend in the direction of the A1C.    However, we can easily do this through blood sugar monitoring.  Blood sugar checks are instantaneous and ideally should be varied throughout different times of the day to really get a full picture of how blood sugar fluctuates.

A1C to Average Blood sugar chart via Mayo Clinic
A1C to Average Blood sugar chart via Mayo Clinic

Here’s an example where A1C alone (without blood sugars) can be totally misleading.  77 year old with Type 2 diabetes currently taking glipizide 5 mg daily.  A1C is 6.4.  Great A1C right?  Great diabetes care right?  At goal right?  The number is good, but this is an average.  This patient had blood sugars ranging from the 40’s to 400’s.  When you see an A1C remember that it contributes to the story, but it doesn’t complete the story, and sometimes may even be misleading.

That same patient could have blood sugars from 80-200 and be extremely well managed, but the A1C alone cannot give you that information.

Here’s another post on blood sugar management and use of Sliding Scale

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Trimethoprim and Hyperkalemia – A Drug Interaction you Should be Aware of

One of the things I enjoy about this site is learning from the donations of others.  Here’s an excellent case of trimethoprim and hyperkalemia.  If you have an interesting case study to share that can help educate healthcare professionals, please contact me.  Here’s the case.

MP is a 77 year old male presenting to the emergency department with a chief complaint of weakness. MP has multiple comorbidities, including hypertension, coronary artery disease, type II diabetes, and pulmonary hypertension. His chronic medications include:

  • Diazepam
  • Amlodipine
  • Digoxin
  • Atorvastatin
  • Spironolactone
  • Glipizide
  • Metoprolol succinate
  • Clopidogrel
  • Lisinopril
  • Aspirin 81mg
  • Nitroglycerin sublingual

Also, of note MP was started on sulfamethoxazole/trimethoprim (Bactrim®) 5 days prior to presentation for a sinus infection.

Pertinent vitals signs and initial findings include a heart rate of 43 beats/minute and prominent T waves per the electrocardiogram.

Pertinent initial labs include: Potassium of 7.3 meq/L, sodium of 125 meq/L, and a digoxin level of 1.2. MP was successfully treated for hyperkalemia and was able to be discharged from the hospital a couple days later after multiple medication adjustments, the primary one being stopping sulfamethoxazole/trimethoprim.

Multiple medications were contributing to the lab abnormalities and likely peaked with the addition of sulfamethoxazole/trimethoprim. Digoxin, spironolactone, and lisinopril (as well as all ACE inhibitors and angiotensin receptor blockers) are known to increase serum potassium levels. Trimethoprim has been found to reduce renal potassium excretion via a similar mechanism as the potassium sparing diuretic amiloride.

This drug interaction needs to be taken seriously. In patients chronically taking a medication known to increase potassium and in whom an antibiotic is needed (for an indication that sulfamethoxazole/trimethoprim could be used), the clinician should consider an alternative agent.

It must also be noted that this drug interaction (sulfamethoxazole/trimethoprim and either an ACE inhibitor or ARB) has been associated with an increased risk of sudden death in a recent population-based, nested, case-control study.

Donated by Joel Van Heukelom PharmD – You can find him on Twitter @jdvanheuk

Looking for more useful clinical medication content? Check out the 30 medication mistakes, from my everyday practice as a pharmacist.

Reference: Fralick M, Macdonald EM, Gomes T, et al. Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: population based study. BMJ. 2014;349:g6196 doi: 10.1136/bmj.g6196.




Epilepsy Sucks – A Day in the Life

I stumbled across this post from a friend on Facebook that she wants the world needs to see.  – Sincere respect and it puts things into a little perspective.

So November is Epilepsy Awareness Month and it has been a rough one so far for G. To spread the awareness and give perspective. I walk you thru a “normal” day for G. Today:
4:35 am- 10 minute long tonic clonic seizure, then exhausted, falls back asleep
5:07 am- 8 minute long tonic clonic seizure that has her right side flaccid and left side seizing, unable to swallow well- so drooling like crazy. falls back asleep
6:24 am- 7 minute tonic clonic seizure- that affects that right side and this time interrupts her normal breathing. falls back asleep
7:15 am- still sleeping, but need to get up for school- to try to keep life as normal as possible. Plus she adores her classmates, her teachers and friends there.
8:25 am- Attempt to make it to school but she does not want to walk- so mom picks her up and we duck and run cuz its darn cold
8:30 am- 3pm – at school- note says- “small pulses on and off…about once an hour” in the am, then “Went to music and PE and did great”, then this afternoon “After 5 minutes of small pulses, they turned into large pulses and her eyes rolled back and facial expression was in an odd position” I get this last one as a text. How scary for G and her para who is caring for her at school.
3pm- ride home from school, Greta is exhausted
4pm- walking around the living room at home and has a DROP seizure where her whole body collapses to the ground without any warning (hate these the most)
5pm- walking around the living room- happy as can be- another DROP
6pm- walking around the living room- another DROP
6:30pm- small pulses for about 5 minutes while eating supper
7:15pm- another $@!**$%^ DROP
think you all get the point…..
Not looking for sympathy- just awareness of what some families live with on a day to day basis. The best thing you can do for families that have to live with epilepsy is pray for their little one or loved one that has to live with this horrible condition, then pray for their families who care for them. Even after 7 years, each seizure breaks a little bit more of their hearts. Then be willing to support them, swear with them, hug them, and pray some more for them. And the families that have to go thru this everyday are some of the lucky victims of epilepsy, as they still have their child around to care for unlike others whose child has died because of seizures.

Funny thing is I often wonder if God hears my prayers when sometimes all a Mom wants to do is swear

Once again- no sympathy needed, just awareness and prayers are appreciated.
Epilepsy sucks-
But G just walked into the office- and gave me a big smile and wants to crawl up on my lap- and that my friends is darn amazing!

Donated by a dedicated mother and daughter trying to battle epilepsy one day at a time.

Drug Induced Nausea – The Clinical Thought Process

Stomach problems can often be a common issue in the elderly and drug induced nausea can sometimes be a challenge to identify due to polypharmacy.  If you look under adverse effects of medications, nausea is a side effect for virtually every medication.  Here’s a medication list to review for drug induced nausea.

Aspirin 81 mg daily

Metformin 1000 mg twice daily

Cymbalta (duloxetine) 30 mg daily

Prilosec (omeprazole) 20 mg daily

Tylenol 1,000 mg three times daily

Percocet 5/325 mg four times daily as needed

Aricept (donepezil)10 mg daily

Zofran (ondansetron) 4 mg three times daily as needed

via imgflip
via imgflip

Now focusing on the medications, the first critical question you should ask to identify possible causes of drug induced nausea is: When did it start?  This is always one of the first questions I think of when assessing a case.  Timing is so critical, not everytime, but most of the time.  Other questions might be are there other symptoms associated like loose stools, heartburn, other GI problems?  Another consideration would be what dose of each medication are they on? (i.e. is it a high dose for that med)  Do they have a diagnosis that might cause their nausea?  Is diet a contributing factor?  Do they have bad times of the day?  or is it more constant?  Just looking at the meds, from my experience, metformin and Aricept are the most probable to cause the issue.  So identifying if either of theses has been started OR increased…sometimes increased gets forgotten about.  Percocet is also another possibility (need to watch out for Tylenol limit as well). I’d like to know how much/if this patient is taking that and try to correlate that with the nausea as well.  –  Just a few tips on trying to identify drug induced nausea!

Here’s a case of drug induced nausea from the past.

Also remember to check out the 30 medication mistakes that all healthcare professionals should know.  Great resource for students and those who teach students!

Medication List Review – Erythromycin

Imodium as needed

Tonight’s Medication List Review – First thing I want you to remember is whenever you see an order for Erythromycin, remember that it has a ton of drug interactions.  So whenever we start, increase or decrease this medication, it can have ramifications on the concentrations of other medications.

I will highlight a couple possible interactions; Erythromycin can increase Abilify (aripiprazole) concentrations.  Here’s a case where dose really makes a difference.  While it is a legitimate concern, my concern would be much higher if this patient was on 30 mg of Abilify daily versus the current 2 mg order.  Atorvastatin concentrations can also be increased due to the erythromycin and is something we need to monitor and be thinking about.

The other question I’d have with the erythromycin is why are we using it?  I’ve seen this type of dosing before and would likely suspect chronic use not for an infection, but for GI motility.  I’m not a big fan of using this due to all the interactions erythromycin can cause, but might have to be an option depending upon the case.

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Interprofessional Medication Education