This week we are discussing Gami, who presents to the clinic for primary care. She is a 48-year -old female, whose history includes Type 2 DM, memory deficits. She is treating the Type 2 DM with cassia cinnamon is also prescribed Aricept and Coumadin.
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Additional subjective data would include dates of diagnosis of current disease processes, pain scale, any adverse events, full surgical history, medical history including why she is being prescribed Coumadin, social history, familial history of disease, mental issues, ethnic considerations, nutritional information, and economic factors that may affect compliance. Objective data should include a full head to toe exam, blood work including A1C, vital signs, BMI, thorough wound check and foot care as well as a memory examination, dosages of all medications. It is important to gather as much relevant information as possible during the initial history and visit in order to be able to constructively evaluate the current treatment and what plan of care may be necessary with these factors included (HealthyPeople.gov, 2018).
Taking a position on the patients use of alternative supplements as the only treatment of a chronic serious disease such as type 2 DM can be a delicate balance of looking at the patient’s preferences and safety and efficacy. Using cassia cinnamon to treat Type II diabetes has been studied in several scholarly articles and show improvement in A1C results. I would monitor her more closely if she insists on using cassia cinnamon exclusively treating her type 2 DM. Cassia cinnamon is contraindicated in people with an allergy to cinnamon or Peru balsam and should be used with caution in patients with hepatic disease as it may cause toxicity and also affect blood glucose (Kwak, Park, & Kwon, 2017). The patient should have INR, platelet counts and closely monitor for signs and symptoms of a declining state of dementia (Wilson, Shannon, & Sheilds, 2015).
Due the patient’s history of type 2 DM , I would assess her lab results – A1C, fasting blood glucose, CMP, CBC, liver and kidney function and overall health and my first choice drug would be a prescription for Metformin 500 mg, PO, BID , with meals (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017). The decision is based on evidence that an additional drug should be added to the regimen of treatment with the cassis cinnamon, based on evidence and trials and regulations, unlike the cassis cinnamon alone, which is not regulated by the FDA(Woo & Robinson , 2014). Metformin is classified as antidiabetic, its mechanism of action is a binding of insulin to the receptors and potentiates insulin action, improves tissue sensitivity to insulin, and is effective in lowering serum glucose (Wilson, Shannon, & Sheilds, 2015). Metformin is 50-60% absorbed in the systemic circulation, is not metabolized, eliminate in urine, and has a half-life of 6.2-17.6 hours. Contraindications include hypersensitivity to metformin, hepatic or cardiopulmonary insufficiency and most serious cardiac issues, DKA, renal disease and impairment with creatinine clearance of 1.5 md/dl, and should be stopped 48 hours prior to surgery (Wilson, Shannon, & Sheilds, 2015). Metformin does carry a black box warning of being associated with potentially fatal lactic acidosis (Wilson, Shannon, & Sheilds, 2015).
Educating the patient on proper diet, exercise, taking all medications as prescribed and notifying the HCP of any side effects or missed doses as well as monitoring BG and moderate use of alcohol. Signs and symptoms of hypoglycemia and lactic acidosis should be given with a return demonstration (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017). Patient should also be made aware of bleeding precautions (Wilson, Shannon, & Sheilds, 2015). Follow up appointments every three months should be adhered to.
Is there any additional subjective or objective information you need for this client? Explain.
I would obtain a full set of vital signs and request a complete copy of her medical records from her former primary care provider (PCP). I would conduct a head to toe assessment and review her past medical and surgical history. I would inquire about her family medical history, history of smoking, alcohol use, and illicit drug use. Additional information needed from her previous PCP includes asking how long she has been diagnosed and taking the prescribed medications as well as how long she has been taking the supplements. I would also inquire about what diagnosis requires the use of the Coumadin and the dose. Has she had any recent lab work to check her PT INR or noted any excessive bleeding or bruising? I would inquire about any other medications she is taking for DMII, if any, and how blood sugars are controlled (i.e. diet, exercise)? I would also ask if the Cassia Cinnamon is the only medication she is using currently for diabetes. I would ask how often she checks her glucose levels at home and if she has an appropriate meter or test strips. I would also ask about any new or existing issues or problems she has noticed. I would discuss why she takes Ginseng and Aricept and the dosages of both.
What would be your position on the Ms. GMs use of alternative supplements for her diabetes and memory? Explain and include contraindications, if any.
I would advise Ms. GM to discontinue the use of Ginseng and Cassia Cinnamon because of the interactions with Coumadin and glucose levels. The Ginseng interacts with Coumadin causing increase or decrease on coagulations and interacts with insulin causing hypoglycemia in people with diabetes (Ginseng, 2018). There have also been reported potential interactions between cinnamon and warfarin and are labeled as significant, which means there is an increased risk of an interaction occurring and are not recommended for use together. Cassia cinnamon contains high levels of coumarins which are likely toxic in high doses (Kawatra & Rajagopalan, 2015).
Are there any additional test/assessments you would complete for this patient given this list of medications? Explain.
Yes. The additional test/assessments I would complete for this patient include clotting times (PT & INR and PTT), and blood glucose levels including an A1C, because these should be closely monitored. I would explain to the patient that, according to NIH (2018), her current use of the supplement’s cinnamon and ginseng with Aricept and Coumadin is not safe. Medications, like Coumadin, require a certain therapeutic range, which may be compromised by the supplements. The use of the supplement can cause the levels to be too high or too low which would cause the medication to either become toxic or sub-therapeutic. Cassia Cinnamon has been reported to worsen liver disease, so I would perform a metabolic panel to check liver function (NCCIH, 2017). A complete blood cell count (CBC) would also be obtained to check for infection, anemia, and assess platelet count.
How might your treatment plan, in terms of medications, differ for this patient? Include the class of the medication, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; contraindications and black box warnings.
Depending on the results of her lab test and how well her glucose has been controlled, I would consider starting her on a medication for her diabetes, like Jardiance. Jardiance is a prescription medicine used along with diet and exercise to lower blood sugar in adults with type 2 diabetes, and also to reduce the risk of cardiovascular death in adults with type 2 diabetes who have known cardiovascular disease. Jardiance tablets contain empagliflozin, an orally active inhibitor of the sodium-glucose co-transporter 2 (SGLT2), which is a new class of medications for the treatment of diabetes type 2. The recommended dose of Jardiance is 10 mg oral tablet once daily in the morning, taken with or without food. In patients tolerating Jardiance, the dose may be increased to 25 mg. Side effects include hypotension, ketoacidosis, impaired renal function and hypoglycemia. The mechanism of action is to assist the kidneys with urination to help remove more excess sugar from the body rather than allowing it to be reabsorbed. It is contraindicated in patients with diabetes type 1 and patients with renal disease. The Food and Drug Administration is adding a warning to the prescribing information and patient medication guide for all drugs in the SGLT2 inhibitor class, linking them with increases in the risk of Fournier’s gangrene, a rare but serious infection of the genital area. Symptoms include tenderness, redness, and swelling of the genitals or the area from the genitals back to the rectum, along with high fever. Patients taking SGLT2 inhibitors who demonstrate these symptoms should get medical attention immediately (Food and Drug Administration, 2018).
What health maintenance or preventive education is important for this client based on your choice medication/treatment?
If Ms. Gm decides she does not wish to stop taking the supplements, she should be educated that Cinnamon supplements appear to be safe for most people for only short-term use and if not taken in large amounts. Some people can develop allergic reactions to cinnamon. Cassia cinnamon contains varying amounts of a chemical called coumarin, which might cause or worsen liver disease, and she should have her liver function monitored (Schneider & Wissink, 2008). I would advise the patient to keep all follow-up appointments and perform regular blood sugar checks and have her PT & INR performed as ordered. Take medications as ordered and always notify care provider of all adverse reactions. Regarding Ginseng, there are various forms of ginseng and depending on the components of the root used, the effects maybe be different, always report adverse, new or worsening reactions.
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