Patient Case Study: Transitioning from Oral to Insulin Therapy for DM

This case study presents the scenario of a 63-year-old diabetic patient initially managed with oral medications (metformin and gliclazide) who was admitted to the hospital with symptoms of dizziness and lightheadedness. The patient's condition deteriorated, leading to a diagnosis change from type 2 to type 1 diabetes, necessitating the introduction of insulin therapy (Novorapid). The case details the medication management process, including the preparation of the 'to take away' (TTA) medications for discharge, emphasizing the importance of patient education regarding lifestyle changes, regular diabetic review appointments, and blood glucose monitoring. The document further explains the mechanisms of action of metformin, gliclazide, and Novorapid in managing diabetes, highlighting their roles in glucose control and potential side effects. The importance of continuous patient monitoring, proper communication between healthcare professionals and the patient, and addressing potential complications or allergies are also emphasized. Desklib is mentioned as a platform where students can find similar solved assignments and resources.

Patient case study
As while I was working on MMT working in the ward this was the only opportunity where I
could speak to the patients about their medications. I found this rotation the most useful
chance to do this as I would be talking to the patient about their medication history and if
they know what they are using their medication for.
As my first patient was a diabetic patient which was 63 years of age. He was currently using
tablets to control his diabetes. They were already using two separate medications which was
both tablets at the time. Metformin and gliclazide. He was admitted into hospital as he was
brought in by a family member he lives with as he had complaints of feeling dizzy and light
headed. He had these symptoms for a week. He also mentioned to me it felt like when he
found out when he was first diagnosed with diabetes. He currently is using metformin twice a
day and gliclazide once daily. As it seemed as the medication wasn’t controlling his diabetes.
He also told me he doesn’t go to his diabetic review appointments at his gp often. I advised
him that these appointments are important and also referred him about lifestyle advice while
having diabetes. This was to do with diet (Horsburgh, 2019).
As when the patient came into hospital his blood level was also too high. I gained this
information via his notes and handover sheet which I can gain access to on the ward. As the
patient came in as a diabetes type 2 patient. He was later diagnosed type 1 diabetes as his he
also confirmed that he did not follow the lifestyle change advice that he was advised by his
local gp.
The patient was prescribed insulin while on the ward, while his blood was still being
monitored. The insulin which was prescribed was novorapid flexpen. As when it was
prescribed for the ward the nurses on the ward will be administering to the patients. The dose
of novorapid will always change as it depends on the patients’ blood levels. This was checked
daily on the ward by the nurses. Three days once the patient was on the ward and receiving
the insulin and his condition started to become more stable. Me and the ward pharmacist

prepared the TTA for the patient to prepare them to go home. When we prepare the TTA
insulin we label the any insulin we dispense without the instructions of how many they
should inject as this will always change depending on the patients’ blood results which they
are able to check at home after being discharged. We also included all of the information that
was needed for the doctor’s discharge summary for the patient and with the valid medication
they left the hospital with.
The patients regular was not changed as they still continued taking the metformin and
gliclazide while starting the new medication novorapid. All of this information was given to
their regular GP (Degner, 2018).
Metformin is defined as a diabetic drug that is used in order to prevent the increasing
scenarios of the risk factor with diabetes. Metformin has been the mainstay of therapy that is
associated with diabetes mellitus for a number of years. Moreover, it is also analysed that
they have various mechanistic properties and that show action in order to prevent the causes
and symptoms of diabetes. The mechanistic aspect of metformin action remained ill-defined.
In addition to this, various advance studies indicate that the drug has their mode of action and
clinical implications that is useful in order to reduce the rising cases of diabetes among the
people. In addition to this, it is analyzed that the glucose-lowering action is performed by
metformin which is specifically promising the specifically targeting metabolic differences
that is associated between normal and abnormal metabolic signaling. To do this, the
knowledge which is usually acquired in order to meet the mechanism with the help of
metformin works that help to formulate a particular treatment which is called Novel
treatment. The centre of the metformin mechanism of action is to alter the metabolism which
is based on the energy formation within the cell. The metformin usually exerts its prevailing
glucose-lowering effect by restricting the hepatic gluconeogenesis and completely opposing
the action of glucagon. In addition to this, the restriction of mitochondrial complex results in
order to create defective AMP and protein kinase signaling in the action to glucagon.
Therefore, the secretion of 5-AMP activated protein kinase are usually dispensable for the
glucose-lowering effect of metformin (Kalafat,, 2018). They usually confess the insulin
sensitivity that mainly focus on modulating lipid metabolism. In addition to this, the make
form might influence the tumorigenesis directly or indirectly with the help of systematic
reduction of insulin level in the body. While taking the aspect of direct way, they are usually

creating induction of energetic stress. In addition to this, it shows the effect that requires for
the investigation that create an understanding of the anti-gluconeogenic action of metformin
within the liver and show various implications of metformin target for the treatment of the
diabetic patient and in the cancer cells.
Gliclazide is a drug which is usually used in the treatment of diabetes with a combination of
metformin. It is useful in order to reduce the complications and risk factors which may be
created during the diabetes or in cancer. Moreover, the drug is a sulphonylurea with an
intermediate half-Life of around 11 hours. They are extremely metabolized and shows that
renal clearance account for only 4% of the total drug clearance. Various studies show the
various mode of action and mechanisms aspect that is relative with the molecules which is
contained and the Azabicyclo-octyl group which consist of some special properties of the
aspect on the basic sulphonylurea moiety. In addition to this, the drug stimulates insulin
secretion through the beta cell of the sulphonyl urea receptor and they show a direct effect on
intracellular calcium transport channels. Moreover, they show their mechanism property in
the normal way by creating some of the physiological alterations in the calcium factors that
they are responsible for the transportation. They show their significance by improving the
abnormal first phase of insulin release in type 2 diabetes and also show the various necessary
effect on the second phase of secretion. The pattern of the secretion of insulin is usually
explained with the help of lower incidence of hypoglycaemic episodes and weight gain
compared with some other sulphonylurea. There is a wide range of reduction in hepatic
glucose production and improvement in the glucose clearance without changing any factor
within the insulin receptors. It is also recommended that the post-receptor effect on insulin
action is generated by the release of hepatic fructose 2-6 diphosphatase and muscles glycogen
synthase. Gliclazide usually minimizes the platelets addition, hyperactivity and increases the
fibrinolysis within the body. These actions are independents on their hypoglycaemic activity
that may be useful for the drug in order to highlight the progression of diabetic
microangiopathy (El-Baz, 2021).
Novorapid is also a drug that is usually used for the treatment of diabetes. While taking the
contrast of the case study, the drug is recommended after the change in the formation of the
combination of metformin and gliclazide. The novorapid shows various therapeutic
indication for the treatment of diabetes mellitus in adults, adolescents, and children age 1 year
and above. Moreover, the major mechanism of action that is associated with the novorapid is
recognised for the treatment in adults, adolescents, and children who has faced the issues of

diabetes for a longer period. It usually contained the active substance insulin that is known as
rapid-acting insulin. In addition to this, the novorapid is defined as a solution for the injection
or with the route of intravenous that is available in the vials, cartridge, and pre-filled pens.
They are only obtained for taking with the help of a prescription. It is usually given by
injection within the skin or in the abdominal, the thighs, and upper arms or is also acceptable
for the intravenous route of novorapid. Moreover, the injection site is always changed for
every injection because it creates redness on the site of injection that is create itching.
However, the patient novorapid injects himself under the skin with novorapid if they are
trained enough to take their field injection in the appropriate places. The novorapid are
provided instantly before the meal also it may be given after the meal if it is required. In
addition to this, the novorapid is normally used in the combination with the intermediate or
long-acting insulin that is provided at least once a day the patient blood glucose is suggested
to be tested on the regular basis in order to find the lowest effective dose (Fagherazzi, 2019).
It is very important to taking care of the patient who is facing the issue of diabetes. Moreover,
the study is usually focus on the monitoring of the patient and fulfilling the requirement of
the insulin. The proper support and care is needed by patient in order to develop quality of
life and health. In addition to this, with the case study, there is no any other type of side effect
or the reaction is evaluated which is associated with the patients. Moreover, the proper
monitoring is useful in order to provide the mechanism of drug which show the recovery. In
addition, the drug is inspection is important in term of effective use of the medicine. The
pharmacist is used to taking care of the medicine which is provided to the patient who is
falling in the risk of diabetes for the long term. In this case study, it is well analysing that the
patient must focus on the relaxation and they communicated with the medical staff regarding
the comfortability. In addition, if any discomfort or not proper recovery is analysing then
communicate with the healthcare professional in order to change the drugs or the medication
which is seen above (Sigal, 2018). The drug novorapid is added due to the ineffective effect
of metformin within the patients. In addition to this, the weekly or the monthly diagnosis of
the patient is used to take in order to know the recovery stage of patient and if the critical
condition is persistent and complication are arising then try to consult with the doctor and the
pharmacist to change the dose, frequency and other for the formulation of comfortability
towards the patients. The proper communication and the coordination with patient is
important in order to know the issue which is associated with the complication of the patient.
In this, it essential to provide proper education to patient for the healthy diet, taking

medication at the timely manner and provide information for their health recovery time to
time that generate motivation to the patient. Therefore, if the complication is rise and patient
getting frustrated and stress and lose their mental health then the counselling work as option
in order to generate the positive behaviour within the patient. In this, if any emergency is
used to occur due the medication error or due to the medication then they must report to the
hospital for that and take respective approach which may be beneficial that reduce the
complication that associated with the side effect or due to the adverse drug reaction. The
action must be associated with the mediate way which provide proper configuration and
create the factor which is responsible for the recovery of emergency condition.
With this, the history of the known allergies regards with the patient is unknown. Usually, if
any kind of allergies is occurring then it must be reported with the healthcare professional
who used to provide proper medication such as antihistamine drug and many more which
reduce the complication of allergies. The most used drug for the allergies is cetirizine
hydrochloride which minimise the risk of allergies and work as antihistamine drug. The
patient social history is known that they use to perform some of the exercise and maintain
their diet which do not enhance the level of complication due to the diabetes. In this, at their
earlier day the patient used to take alcohol and do smoking. The history is unknown and it is
not track for the longer period. Moreover, the study regards with the patient show various
aspect that include inspection and monitoring of the drug for the prolong time which is
related with composition and formulation of drug (Hasan, 2020).
In addition to this, the metformin which is prescribed to the patient is related with the class of
Biguanides and the drug named Gliclazide is associated with the class of sulphonyl urea.
These drugs are used to prescribe the treatment factor of diabetes. In addition to the, the drug
which is change in the middle when the response of these is not enough to treat the patient in
the effective way. The drug which is added within the form of treatment is novorapid which
is associated with the class of fast acting insulin and the analogues which is used in the
treatment of the diabetes. The main purpose of adding this drug is because it is modern
insulin with the rapid acting effect. Therefore, the insulin product is used to improve the
version of human insulin. The novoraopid is usually help to reduce the high blood sugar level
in the adults, adolescent and the children which is age up to the 1 year and more who is living
the disease of diabetes mellitus.

The drug-drug interactions which is associated with the metformin interaction are usually
analysed with the impact of 351 drugs which are taking under the consideration that follow
with the metformin. They are categorised as 19 that show major aspect and 303 shows the
moderate and 29 are related with the minor interaction. In this, some of the drugs which
comes under the major aspect that have a clinically significant and avoid the combination
with the metformin. They usually create complications with the patient they usually are lactic
acidosis, B12 deficiency, Synthroid that is also called as levothyroxine. In this, there are
some other medications which is shows moderate interaction that include furosemide,
hypoglycaemia and many more. There are some unknown interactions which is frequently
checked with the metformin that includes aspirin, atorvastatin, metoprolol, and many more
drugs are shows unknown reactions with the metformin. Drug-drug interaction is very
necessary to know in order to understand the consequences and complications which may be
associated with the patient after taking the drug in the combinations. Sometime, the
metformin shows drug and food interaction that is related with the alcohol that create severe
headache within the patient (Williams, 2020).
With the contrast with the drug, the patient maybe feel that their drug has unresponsive and
shows less effect within the body. This case study is usually based on the pharmacological
action that include pharmacodynamic and pharmacokinetic property in order to identify the
medication which is prescribed as an intervention for the patient to reduce the complication.
In addition to this, the excessive or inappropriate use of medicine main cause various
complications which include nausea, vomiting, diarrhoea and intrinsic hypothermia or
hyperthermia. There are various formulations that may not be suitable with the patient and
create same issues that related with the side effect of the adverse drug reaction. It is very
necessary to take the drug in order to create understanding regards with the glucocorticoid or
mineralocorticoid. In addition to this, the patient taking concerned in order to take the drug
before or after the food. Therefore, the food drug interactions are also restricting the
therapeutic effect of the drug in the body that show average potential effect of the drug that
create less activity in the body. These issues are usually resolved or manage with the help of
proper education that is taken with the help of pharmacist for the healthcare professionals that
create understanding for the administration of drug. If any emergency is occur regards with
the drug, it is essential to inform the health care professional and pharmacist to change the
doses form of drug that reduce the maximum medication error.

Diabetes is usually a chronic progressive metabolic disease which is characterized by
hyperglycaemia due to absolute or relative deficiency of insulin hormone. According to the
World health organisation approx. 350 million people in the worldwide facing the issues of
diabetes. These number are usually going to be double at the end of 2030 without any
intervention or strategies. The requirement of the diabetic patient is limited and not only
limited to the proper glycaemic control but also so correspondence towards the preventing
complication. In addition to this, the disability limitations and rehabilitation is also a main
cause of having a diabetes. There is very essential self-care behaviour which is used by
people in order to reduce or minimise the complication of diabetes. It is essential to predict
the good outcome of health that show the references of healthy eating, physically active,
monitoring on blood sugars, taking medication in the proper way, a good problem-solving
skills, healthy coping skills and risk reduction behaviour. These all aspects within the diabetic
patient are very necessary to reduce the stress and frustration that create complications with
the rise and consequences of diabetes. All these behaviours are usually creating a positive
correlation with the good glycaemic control and show the reduction of consequences and also
approach a proper improvement in quality of life. Therefore, the individual for the person
who is facing the issues of diabetes shown that the used to make a dramatic impact on the
progression and development of their disease by taking the participation in the aspect of own
care (Forouhi and Wareham, 2019).
It is very essential to take the patient feedback which is helpful to provide a better concern for
the others. In addition to this, the feedback is helpful for the healthcare professionals and
other medical staff to motivate and inspire them to keep their working for the improvement of
patient quality of life. Overall, patient usually faces higher number of issues due to diabetes.
Moreover, the medication is also approached for the longer period which create positive
impact on the reduction of diabetic complications and consequences.

REFERENCES
Books and Journals
Forouhi, N.G. and Wareham, N.J., 2019. Epidemiology of diabetes. Medicine, 47(1), pp.22-27.
Williams, R., Karuranga, S., Malanda, B., Saeedi, P., Basit, A., Besançon, S., Bommer, C., Esteghamati, A.,
Ogurtsova, K., Zhang, P. and Colagiuri, S., 2020. Global and regional estimates and projections of diabetes-
related health expenditure: Results from the International Diabetes Federation Diabetes Atlas. Diabetes research
and clinical practice, 162, p.108072.
Hasan, M.K., Alam, M.A., Das, D., Hossain, E. and Hasan, M., 2020. Diabetes prediction using ensembling of
different machine learning classifiers. IEEE Access, 8, pp.76516-76531.
Fagherazzi, G. and Ravaud, P., 2019. Digital diabetes: Perspectives for diabetes prevention, management and
research. Diabetes & metabolism, 45(4), pp.322-329.
Sigal, R.J., Armstrong, M.J., Bacon, S.L., Boule, N.G., Dasgupta, K., Kenny, G.P. and Riddell, M.C., 2018.
Physical activity and diabetes. Canadian journal of diabetes, 42, pp.S54-S63.
Diabetes Prevention Program Research Group, 2019. Long-term effects of metformin on diabetes prevention:
identification of subgroups that benefited most in the diabetes prevention program and diabetes prevention
program outcomes study. Diabetes Care, 42(4), pp.601-608.
El-Baz, A.M., Shata, A., Hassan, H.M., El-Sokkary, M.M. and Khodir, A.E., 2021. The therapeutic role of
lactobacillus and montelukast in combination with metformin in diabetes mellitus complications through
modulation of gut microbiota and suppression of oxidative stress. International Immunopharmacology, 96,
p.107757.
Degner, N.R., Wang, J.Y., Golub, J.E. and Karakousis, P.C., 2018. Metformin use reverses the increased
mortality associated with diabetes mellitus during tuberculosis treatment. Clinical Infectious Diseases, 66(2),
pp.198-205.
Kalafat, E.R.K.A.N., Sukur, Y.E., Abdi, A., Thilaganathan, B. and Khalil, A., 2018. Metformin for prevention
of hypertensive disorders of pregnancy in women with gestational diabetes or obesity: systematic review and
meta‐analysis of randomized trials. Ultrasound in Obstetrics & Gynecology, 52(6), pp.706-714.
Horsburgh, S., Barson, D., Zeng, J., Sharples, K. and Parkin, L., 2019. Adherence to metformin monotherapy in
people with type 2 diabetes mellitus in New Zealand. Diabetes research and clinical practice, 158, p.107902.
Jenkins, A.J., Welsh, P. and Petrie, J.R., 2018. Metformin, lipids and atherosclerosis prevention. Current
opinion in lipidology, 29(4), pp.346-353.

SHE, X. and LIU, Y., 2021. Effects of NovoRapid and biosynthetic human insulin on Cys C, HCY and
pregnancy outcomes in patients with gestational diabetes mellitus. Journal of Public Health and Preventive
Medicine, pp.142-145.
Shiramoto, M., Yoshihara, T., Schmider, W., Takagi, H., Nowotny, I., Kajiwara, M. and Muto, H., 2021.
Pharmacokinetic and pharmacodynamic similarity between SAR341402 insulin aspart and Japan-approved
NovoRapid in healthy Japanese subjects. Scientific reports, 11(1), pp.1-7.
Nolan, J., Rush, A. and Kaye, J., 2019. Glycaemic stability of a cyclist with Type 1 diabetes: 4011 km in 20
days on a ketogenic diet. Diabetic Medicine, 36(11), pp.1503-1507.
Carracher, A.M., Marathe, P.H. and Close, K.L., 2018. European Association for the Study of Diabetes 2017.