Mary Barna Bridgeman, PharmD Rupal Patel Mansukhani, PharmD
Case 1—Prophylactic Aspirin Use
GV is a 53-year-old man who comes to the pharmacy to fill a prescription for metformin. When counseling him regarding the use of this new medication, he informs you that he was diagnosed with diabetes 1 year ago and has been trying to control his blood sugar with diet and exercise alone. He states that his friend, who also has diabetes, recommended he take a “baby” aspirin every day and now he would like to know if you recommend he act on his friend’s suggestion. Upon further questioning, you learn he is a smoker who has smoked 1 pack of cigarettes per day for the past 30 years, and that his father died from a heart attack at the age of 38 years. He has no other medical conditions and is currently only taking metformin 500 mg twice daily. His blood pressure today is 145/90 mm Hg. Would you recommend GV take aspirin 81 mg daily?
GV would be an appropriate candidate for aspirin therapy for primary prevention of heart attack or stroke.
According to the American Diabetes Association, low-dose (75-162 mg) daily aspirin therapy should be considered for primary cardiovascular disease (CVD) prevention in patients with type 1 or type 2 diabetes at increased cardiovascular risk. This includes most men 50 years old or women 60 years old who have at least 1 additional major risk factor (ie, family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria).
Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk, such as for men younger than 50 years and women younger than 60 years who have no major additional CVD risk factors, because the potential adverse effects from bleeding complications likely offset the potential benefits.1
GV has multiple CVD risk factors, including his age, smoking history, and family history. He also may have hypertension, based on your evaluation of his blood pressure, so physician referral before initiating aspirin therapy would be prudent. Uncontrolled blood pressure can lead to an increase bleeding risk with aspirin therapy. Once his blood pressure is under control, GV should be initiated on aspirin 81 mg daily.
Case 2—Alternate Site Testing for Blood Glucose Monitoring
RB is a 28-year-old woman who comes to the pharmacy for a refill on her blood glucose test strips. She describes recently watching a commercial for her blood glucose monitor that advertised the use of “alternate site testing.” She says that fingertip testing does not bother her at this time, but she would like to learn about other options for testing her blood sugar. She is wondering if you can describe which alternate testing sites are appropriate for testing her blood glucose. Upon questioning, she states that she checks her blood sugar twice daily, once right after breakfast and then in the evening right after exercising. She says 90% of the time she has normal readings, but 10% of the time she gets either low readings or high readings. Would RB be a candidate for alternate site testing? What counseling can you provide RB at this time regarding alternate site testing?
Some of the newer blood glucose monitors allow for use of alternate testing sites, including the palm, forearm, upper arm, thigh, or calf. These offer convenient alternatives for those patients who are not comfortable using their fingertip, because the skin of these alternate areas contains fewer nerves than the fingertip, and so testing is less painful.
At this time, however, RB should not be using alternate site testing for any of her measurements. RB is not the ideal candidate, because alternate site testing should only be used when blood sugar readings are stable: immediately before a meal, when fasting, and at bedtime. 2 Because RB states her blood sugars are not always stable, it may be beneficial for her to continue to check her fingertip for more accurate testing.
Additionally, it is important to remind RB that she is not a candidate for alternate site testing because she checks her sugar immediately after a meal and after exercise. During these times, blood sugar values may fluctuate and the fingertip site is most accurate. It is important to tell RB that anytime she thinks her blood sugar is low, or if she believes she is suffering from hypoglycemia, she should also test with her fingertip. PT
Dr. Bridgeman is an internal medicine clinical pharmacist in Trenton, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.
1. American Diabetes Association. Standards of medical care in diabetes—2011.Diabetes Care.2011;34(1):S31.
2. Bina DM, Anderson RL, Johnson ML, Bergenstal RM, Kendall DM. Clinical impact of prandial state, exercise, and site preparation on the equivalence of alternative-site blood glucose testing. Diabetes Care. 2003;26:981-985.