Clinical Twisters: Fixing therapeutic non-compliance

October 23, 2006

A 63-year-old Hispanic man, P.C., seen in your diabetes clinic, is complaining of burning and aching in his legs and feet. His current daily drugs include glipizide ER (Glucotrol XL, Pfizer) 10 mg, pioglitazone (Actos, Takeda) 45 mg, metformin ER (Glucophage XR, Bristol-Myers Squibb) 500 mg, escitalopram (Lexapro, Forest) 10 mg, atorvastatin (Lipitor, Pfizer) 40 mg, ezetimibe (Zetia, Merck/ Schering-Plough) 10 mg , aspirin 325 mg, and ramipril 10 mg. Although his current fasting blood glucose is 100, his A1c=9. Upon questioning him, you find he has not been taking his medicine regularly since he lost his job and insurance last spring. What do you recommend?

A 63-year-old Hispanic man, P.C., seen in your diabetes clinic, is complaining of burning and aching in his legs and feet. His current daily drugs include glipizide ER (Glucotrol XL, Pfizer) 10 mg, pioglitazone (Actos, Takeda) 45 mg, metformin ER (Glucophage XR, Bristol-Myers Squibb) 500 mg, escitalopram (Lexapro, Forest) 10 mg, atorvastatin (Lipitor, Pfizer) 40 mg, ezetimibe (Zetia, Merck/ Schering-Plough) 10 mg , aspirin 325 mg, and ramipril 10 mg. Although his current fasting blood glucose is 100, his A1c=9. Upon questioning him, you find he has not been taking his medicine regularly since he lost his job and insurance last spring. What do you recommend?

Various landmark studies have proven that increased A1c results in devastating complications of diabetes. Clearly, P.C. is out of control with A1c=9. The most likely reason for his noncompliance is economical, due to a loss of his insurance coverage.

First, discuss the importance of diabetes self-management-diet, exercise, monitoring, etc. Next, emphasize the role of medications in controlling glucose levels and suggest medication assistance programs via PhRMA, such as Together Rx.

Jag Khatter, R.Ph., Pharm.D., CGP SeniorMed PharmacyAurora, Colo.

This is all too common in the elderly. As people retire, there is a gap in insurance coverage until they are eligible for Medicare. Unfortunately, health conditions do not wait. Complicating P.C.'s case is Type 2 diabetes, requiring multiple drugs; his probable diabetic neuropathy will add to his lengthy drug profile.

We can simplify P.C.'s drug regimen and reduce costs by using combination drugs and switching to less expensive equivalent drugs. I'd continue glipizide ER, escitalopram 10 mg, but aspirin at 81 mg daily. Changing ramipril to the generic lisinopril 40 mg should provide equal efficacy; switching pioglitazone and metformin ER to rosiglitazone/metformin (Avandamet, GlaxoSmithKline) 4/500 not only will decrease cost, but rosiglitazone has fewer drug interactions than pioglitazone. A similar change from atorvastatin and ezetimibe to the combination drug simvastatin/ezetimibe 10/80 (Vytorin, Merck/Schering-Plough) will simplify his regimen and reduce costs. For treating neuropathy, an inexpensive option would be imipramine 10 mg daily titrated as needed.

He should have lipid, liver, and metabolic panels drawn 30 days after changes and every six months thereafter, A1c in three months, and regular BP monitoring. These changes will reduce costs and simplify his regimen, but a referral to a social worker for patient assistance is in order.

James Dickens, Pharm.D., CGP, C.Ph.Consultant Pharmacist, APS LongwoodClinical Assistant ProfessorUniversity of Florida, College of Pharmacy Orlando