The following case study focuses on a 26-year-old male patient resident in the United Arab Emirates (UAE) who called an emergency ambulance for himself complaining of ‘sugar problems’. The ambulance arrived and, using a standard procedure, the two person crew carried out an assessment of the patient and obtained a thorough history (Caroline, 2008). The treatment outcome was then performed using a step-wise decision-making technique, in accordance with clinical operations.
On the arrival of the ambulance crew, a general impression of the patient was formed. The patient appeared well, and was sat up in a chair, alert. The initial assessment indicated the patient to be in a stable condition with no immediately obvious problem. Vital signs measured and recorded as part of the assessment included: oxygen saturations, cardiac monitoring and blood glucose levels, all of which were within normal parameters. A more in-depth assessment was then performed as no immediate life threats were discovered (Caroline, 2008). The patient's body mass index (BMI) was approximated at 30, by weight: 210 lbs, and height: 70 in. The BMI correlates with direct measures of body fat, such as underwater weighing. However, these methods are not available in the pre-hospital environment; therefore, this measurement is a simple alternative (Centers for Disease Control and Prevention, 2014).
Throughout the assessment and history taking the patient did not complain of any signs or symptoms. It was stated that he called for an ambulance as he was concerned and wished for his ‘sugars’ to be checked because he was diabetic. More in-depth history taking was difficult due to a language barrier, and the patient did not seem to know much about his general health and pre-existing conditions. His wife had his medications, which consisted of: metformin (glucophage) oral 500 mg once daily, glipizide oral 100 mg once daily, liraglutide subcutaneous injection 1.2 mg once daily, simvastatin oral 40 mg once daily, and candesar (candesartan) oral 4 mg once daily. Some of the medication appeared to be prescribed whereas others, specifically the metformin, glipizide and simvastatin, were not. The patient had been taking these medications for two years because he believed himself to be diabetic. The patient purchased over-the-counter medications and adhered to a regime because he ‘felt like he needed them’, due to his mother taking insulin for diabetes and so he believed he must also have this illness. He then went to a clinic and informed them of the medications he was taking and his supposed medical history of diabetes. Without a review and thorough assessment, including blood sugar analysis, he was then prescribed liraglutide and candesar. A diabetes prognosis should stem from blood analyses, such as a fasting plasma glucose test (National Institute of Diabetes and Digestive and Kidney Diseases, 2014).
The patient lived in a middle class home together with his family: wife, mother, father and two children. His mother was a diabetic on insulin; when asked he assumed that he must be one also. He was a smoker. There were numerous plates of food laid out, indicating the families' diet. These consisted of Arabic sweets, among other things. He also stated that he does not like water to drink, but drinks a lot of tea.
Management of this patient was difficult as he was asymptomatic. However, he required transfer to a medical facility for further assessment including: blood analysis due to possible adverse drug reactions (ADRs) or drug interactions (DIs). The patient described has not complained of any adverse reactions or interactions; however, he was susceptible, as will be discussed throughout this review.
Diabetes in the United Arab Emirates
The World Health Organization (WHO) defines diabetes as a:
‘Metabolic disorder of multiple aetiologies characterised by chronic hyperglycaemia with disturbances of carbohydrate, fat, and protein metabolism that results from defects in insulin secretion, insulin action, or both’
Type II diabetes is the most common form, and typically develops later in life (Caroline, 2008).
In 2013, research by the International Diabetes Federation suggested that approximately 382 million people worldwide are living with diabetes. The UAE was ranked by this organisation as 15th in the world rankings of percentage populations diagnosed with type II diabetes, with 18.98% of the population suffering with the disease (Imperial College London Diabetes Centre, 2013). Type II diabetes is prevalent in the UAE, and is diagnosed at a younger age compared to other areas. There has been a large rise in the number of people diagnosed with type II diabetes in the UAE (Imperial College London Diabetes Centre, 2013). The prevalence of this disease has increased dramatically in the Arabic speaking countries—such as the UAE—over the last three decades (Badran and Laher, 2012). This may be due to lifestyle, religion, diet and/or genetics.
As economic growth has accelerated in the Middle East, so has the movement of the populations to urban areas where people are more likely to adopt sedentary lifestyles and high calorie diets, contributing to the increased prevalence of obesity and diabetes in the area (Badran and Laher, 2012). Obesity is a major causative factor to the development of type II diabetes, as shown by the positive correlation between increases in BMI and the risk of developing type II diabetes (Nguyen et al, 2008).
Health education has not been able to keep up with this acceleration. A lack of knowledge is a contributing factor to poor diet, obesity and, therefore, the development of type II diabetes (Imperial College London Diabetes Centre, 2013). Health education improvements will increase awareness regarding risk factors, complications and management of the disease. Therefore, the Imperial College London Diabetes Centre (2013) is continuing to increase programmes—in the community, for example—in an effort to slow increase in the disease. A study of 3 003 diabetic patients in Kuwait reported that 27.5% of diabetic patients were illiterate, while 15.5% were better educated (Abdella et al, 1998). The patient in the report, however, was not illiterate but may have underappreciated the importance of regular assessment and maintenance of a disease such as diabetes. This is evident in the described patient's reasoning behind his self-medicating. Although the study suggests that general education in school effects lifestyle choices, it may be said that if illiterate then any efforts or advertisements to improve education in health will be difficult. This study is also not specific to the country of the patient; however, it is in the Middle East and so shares socio-economic characteristics signifying a comparable relationship in the UAE.
Other socio-economic factors contributing to the prevalence of diabetes in the Middle East include marriage and ‘consanguinity in marriage’ (Anokute, 1992). Anokute's study of diabetes cases in Saudi Arabia suggests that consideration should be given to the potential effects of marriage on lifestyle in Arabic speaking cultures—they become less active after marriage, tend to eat together, and tend to reinforce increased food intake. Therefore, leading to the increased body weight and diabetes prevalence observed in the Middle East. More research, however, is required into the connection between consanguinity in marriage and type II diabetes prevalence in Arabic-speaking countries. Previous studies—for example Anokute's (1992)— are dated and involve a small subject base.
There are many illnesses and conditions treated by non-prescription drugs. These should be taken under advice from a medical professional, e.g. a pharmacist or general practitioner. The prevalence of non-prescription drug use, as well as the potential for therapeutic misuse requires more attention (Covington, 2006). In the described case study, the patient is adhering to an effective drug regime, suggested by the randomised controlled study by Nauck et al (2009). However, he was treating an undiagnosed condition, therefore subjecting himself to ADRs, DIs and polypharmacy, possibly unnecessarily.
Symptoms of diabetes
When taking a thorough history of the patient described, it became evident that they did not suffer with diagnosed diabetes due to lack of knowledge, labelling of medication and complete lack of symptoms. It is important to note that had this been an emergency situation this issue may not have been identified. Therefore, it is important for paramedics even in non-emergent situations to carry out a full patient assessment including history.
Common symptoms of undiagnosed diabetes include: urinating often, feeling very thirsty or very hungry despite increasing consumption, suffering with extreme fatigue, blurry vision, or cuts/bruises that are slow to heal. The patient may also be experiencing weight loss despite an increase in food intake; however, this is more typical of type I diabetes. In type II diabetes a patient may experience tingling, pain, or numbness in the hands/feet (American Diabetes Association (ADA), 2014).
Pharmacological effects on undiagnosed diabetes
The risk of ADRs and DIs occurring are increasing (Craig and Eves, 1987), particularly when self-medicating for an undiagnosed condition, and taking over-the-counter medications concurrently with prescription medications. This form of poly-medicating is common in elderly patients (Craig and Eves, 1987), which may be due to increased confusion as well as a lack of knowledge about their conditions. In referring to this specific case study, the patient appears to be misusing drugs due to a lack of education regarding the condition of diabetes. He does not appear to understand how it is diagnosed and the importance of a reliable treatment plan. Little has been done to reduce this risk in the Middle East. The majority of research in this area examines the misuse of medications in elderly patients as this represents an important health concern (Simon et al, 2005); however, this should not just be a concern for one specific patient group as it is becoming more common across diverse groups (Cooper, 2013). Regularly inappropriate adherence to medications is attributed to limitations and inadequacies in their health care, i.e. the pharmacist or clinic physician did not realise that the patient had not been diagnosed. However, often the patient's perceptions and outcomes are not investigated—it is merely assumed (Murray and Kroenke, 2001).
Self-medicating, when done appropriately, may have a niche role in diagnosed chronic conditions, e.g. reducing costs of the health industry. Yet, this in turn may compromise patient care and treatment due to lack of knowledge of potential ADRs, DIs and polypharmacy effects. Further research is required into the area of self-medicating for undiagnosed diabetes before utilising this niche role. On the other hand, it is assumed that the patient is merely concerned about their health. More investigation is needed into the possibility of underlying psychological disorders; this drug using behaviour may be disguised as treatment for a medical condition.
Non-pharmacological factors effecting diabetes and medications
The non-pharmacological factors to be considered are based on the physiological and social aspects of this case study. Apart from the possibility of misdiagnosis and inappropriate use of medications, based on the evidence, it is likely the patient will be affected by both pharmacological and non-factors (Garber and Sharma, 2009).
The prevalence of obesity has increased worldwide in past years (Björntorp, 1997). It is a significant risk factor for several diseases, such as cardiovascular and endocrine diseases, and more specifically, type II diabetes. Obese patients are more likely to develop co-morbidities, including left-ventricular hypertrophy (Duflou et al, 1995). Usually, doses of drugs are customised according to body weight or size and the patient's condition. As well as this, the prescriber should also take into account body-composition factors such as age and gender. In the obese patient body composition alters with increased weight, therefore effecting medication and prescription efficacy (Alvarez et al, 2010). The physiological changes produced by obesity can markedly affect the distribution, binding and elimination of drugs. Obesity increases both fat and lean masses compared with non-obese subjects of the same age, height and sex. These changes in tissue distributions can affect the volume of distribution of the anaesthetic drugs (Adams and Murphy, 2000), and so may influence others. Changes induced by obesity that may affect the profile of drugs include: the absolute increase in total blood volume, cardiac output, and alterations in plasma protein binding (Cheymol, 1993). Obese patients can also show changes in haemodynamic status and regional blood flow which further affects drug pharmacokinetics. Fat tissue receives significantly less cardiac output, compared to viscera and lean tissues. The reduction in cardiac performance induced by obesity itself could further reduce tissue perfusion, therefore reducing drug distribution (Cheymol, 1993). This presents a multitude of difficulties to medication prescription. The patient described has indicated no knowledge of these factors and effects when purchasing the medications. Metformin, for example, is usually a relatively well tolerated medication for obese patients with diabetes (Bardin et al, 2012). It is the first line therapy for the management of type II diabetes as an insulin sensitising agent. Current dosing methods of metformin are carried out empirically; the antihyperglycaemic activity is generally dose dependent, however. Pharmacokinetic variability has also been suggested, therefore making it difficult to prescribe in the obese patient. On the other hand, there is currently poor adherence to dosing guidelines (Duong et al, 2013). The patient described may therefore not be taking the most effective dose to have a positive outcome on their glycaemic control.
Obesity also induces change in hepatic and renal function, which may modify drug elimination. Obese patients usually show fatty degeneration of the liver, which may further evolve into liver fibrosis. Hepatic clearance can be normal or even increased in obese patients. Renal clearance increases in obesity because of the increase in kidney weight, renal blood flow and glomerular filtration rate. It is difficult to calculate an accurate dose for renally excreted drugs as standard formulas are inaccurate due to the above alterations in physiology (Snider et al, 1995). The patient is at risk of renal inefficiency due to obesity, poor lifestyle and diet (dehydration). The elimination of drugs is carried out primarily by the kidneys. This first order kinetics is therefore affected by the efficiency of the renal system (Atkinson et al, 2007). The rate at which substances are excreted can be described in terms of clearance; a virtual measure of the volume of plasma from which a substance is completely removed by the kidneys per unit of time (Germann and Stanfield, 2005). So, for reliable medication adherence a full medical assessment is essential to not only reduce the likelihood of ADRs and DIs, but also to ensure drug efficiency in terms of possible altered pharmacokinetics in the obese patient. Obesity may have a significant effect on pharmacology and therefore should be considered as an indirect pharmacological factor.
The effects of obesity on the binding of drugs to plasma proteins are still unclear. It has been reported that the increased concentrations of triglycerides, lipoproteins, cholesterol and free fatty acids may interfere with protein binding of some drugs, increasing their free plasma concentrations. On the other hand, the increase in concentrations of acute phase proteins, including alpha-1-acid glycoprotein, observed in the obese patient may also increase the degree of binding of other drugs, reducing their free plasma concentrations (Barbeau et al, 2002). This again suggests the influence obesity will have on the pharmacokinetics of metformin in the described patient.
Poor diet is a contributing cause to obesity and diabetes, and the primary treatment for both is nutrition and diet control. However, several metabolic studies have reported that inclusion of a moderate amount of dietary sucrose within a balanced diabetic diet does not elicit detrimental effects on glycaemic control (Franz et al, 2002; Janket et al, 2003, whereas others such as WHO consider diet and exercise as important components in the treatment of type II diabetes (WHO, 1999). Appropriate use of diet and exercise can improve insulin sensitivity and glycaemic control and decrease the need for oral medications or insulin (Chandalia et al, 2000). So, there is some controversy over the optimal diet for adults with type 2 diabetes, i.e. high fibre, glycaemic index approaches, and low versus moderate fat. Overall, a common consensus to increase consumption of fruits and vegetables and decrease daily consumption of saturated fats is followed (ADA, 2002).
Conclusions
Overall, taking medications when not clinically necessary may encourage the body to reduce or cease normal functions. It is unnecessary and can have unwanted side effects. Systems would start to rely on the pharmaceuticals in the long term. However, further investigation is required due to a lack of relevant evidence.
The reviewed patient put himself at unnecessary risk from the ADRs and DIs identified by purchasing over-the-counter medications for an undiagnosed condition. This review highlights a wider health system issue in the UAE. A lack of health care and prescription system links, such as electronic medical records, means patients are less likely to have a holistic comprehensive health plan that follows them throughout their life time (Hillestad et al, 2005). Therefore, interaction is more ad-hoc, sporadic and less efficient.
Health education is also highlighted as an issue during the review. Organisations such as the Imperial College London Diabetes Centre are endeavouring to improve health education (Imperial College London Diabetes Centre, 2013). Should the patient have fully understood his mother's condition, he may not have been so ready to self-diagnose diabetes and seek medication.
In the end, the evidence behind medication adherence and misuse are prevalent, but not specific to this case study, therefore further research and investigation again needs to be carried out. On the other hand, it may be suggested that the author's personal experiences are not significant in comparison to other issues, therefore it is not deemed necessary. The patient in this case is overall likely to benefit from non-pharmacological interventions (Garber and Sharma, 2009) as a preventative measure to avoid a future diagnosis of type II diabetes as well as cardiovascular and kidney disease.