Applied Pathophysiology And Pharmacology In Acute And Long-Term Conditions
A 56-year-old male, known as “Ade”, for the purpose of this assignment, was presented with diabetic foot ulcer on the right big toe, unsealing for 6 months with history of other disease condition as a result of untreated diabetes, like hypertension, dyslipidaemia and blurred vision. Surgical history is substantial for an atherectomy of the right popliteal artery, this was done 4 years ago, and he been living with type 2 diabetes for over 11 years. Mr. Ade’s father is known to be hypertensive, and his mother with history of type 2 diabetes is current recovering from a recent episode of heart attack. Ade works as a night guard in neighbouring estate, an irregular smoker and ex alcoholic, quit one year ago, no known allergies. Initial examination reveals temperature 36oc, heart rate 74 bpm, BP 104/54mmHg, BMI 40.2. Visual evaluation of right lower limb according to NICE guidance revealed ankle swelling, redness mild tenderness, local rise in temperature, 2×1 cm swelling crack on the heel of the right foot. The diabetic foot ulcer has been previously dressed with silver dressing and was changed every second day for 2 weeks without improvement. He has been taken oral antibiotics (Metronidazole 1 x 500mg and Dicloxacillin 3 × 250mg) for 2 months because of Mr. Ade’s frequent hospital visit for wound dressing, new approach to modify his wound dressing was initiated. Samples were collected after washing of Ade’s wound with portable tap water as recommended by (NICE, 2009) guideline to reduces exudation and odour. Microbial culture of wound sample was collected after sharp debridement with Mr. Ade’s oral permission.
Ade’s case is an example of difficulties of delayed diabetes type 2 treatment and I will be focusing on the pathophysiology of diabetes, the pharmacology of his drug and UK’s guidelines for diabetes treatment.
Health care provider’s concern about late diabetes diagnosis is patients’ risk of developing foot ulcer due to macro and microvascular diseases which in most cases leads to neuropathy, peripheral vascular anomalies, peripheral arterial disease (McCance and Huether, 2018). The typical outcome of untreated case of diabetes is Ade’s leg ulcer and it has also significantly affected his self-confidence and forced him to socially isolate himself from the community by staying indoor. He is also unable to mobilize freely due to pain.
According to Shaw et. al., (2010), incidence of diabetic mellites is anticipated to surge more than 50% by 2030 as it currently affects 9.5% of the world’s population while Catrina and Zheng, (2016) further explained that one of the long-lasting effects of continued hyperglycaemic condition is diabetic foot ulceration (DFU) which is majorly categorised by non-healing wound of the limbs and this may lead to amputation if diabetes is not controlled.
Owing to the total number of people living with diabetes worldwide, it has been estimated that 15% of the diabetic population has a higher risk of DFU evolving in their lifetime (Boulton, et. al., 2005), leading to an endpoint of frequent amputation that influences the life quality of diabetic patients, Mantovani, et. al., (2017) support that 50% of patients who go through amputation do not survive as they are unable to gain their confidence and function in the society.
Type 2 diabetes is fast evolving and it risk level is linked with low income level 40%, uneducated population risk level of 41% and 31% low socioeconomic status (Skyler et. al.,2017). Sidorchuk, (2011) raised concerns about the growing type 2 diabetes prevalence among the youth of Hispanics/Latinos, Pacific Islanders, American Indians, Asians, Africans and Americans of Africa Origin as extreme high threat of type 2 diabetes conditions.
A raised blood glucose condition is a result of group metabolic disease where the body’s insulin hormone secretion capacity, action or both is impaired by either genetic factor, old age or autoimmune deficiency (McCance and Huether, 2018). In type 2 diabetes, beta-cells of the pancreas tolerate insulin production despite its reduced capability but after a while and they get damaged and can no longer survive the body’s insulin organ’s receptor signal for glucose uptake. The inability of the beta cells to handle the body’s high demand leads to constant raise in blood glucose level then retina, renal glomerulus and the nerves develop diabetes-specific diseases (Agardh, et. al., 2010).
Schreiber et. al., (2015) explain that diabetic neuropathy occurs when there is an inconsistency between nerve filament injury and mending following elongated period of raise glucose level in the blood and it affects over 90% of people living with diabetes. Furthermore, it is a common diabetes disorder and the loss of sensation due to nerve damage affects the autonomic and limbs sensory fibres leading nerve pain which is diabetic neuropathy warning sign.
Likely neuropathy mechanisms progressions are protein kinase C, the polyol path, nonenzymatic glycation, poly (ADP-ribose) polymerase, polyol path, hexosamine path, oxidative stress and the decrease of neurotrophic factors which are metabolic effect from peripheral nerve damage (Yagihashi et. al., 2011). The difficulties of these metabolic effects and other confounding factors may lead to nerve damage due to the result of continued hyperglycaemia confirming the past studies that over 60% of DFU neuropathy is the outcome increasing hyperglycaemia stimulated metabolic anomalies.
Manifestation of neuropathy in diabetic patients is via the nervous system, motor and autonomic sensory mechanism and expressed loss of pain because of inequality between the friction and expansion of the foot leading to destroyed foot pressure point, then the capability of the foot to nourish the overlaying skin is destroyed leaving the skin dry and highly prone to cut and consequent infection progression, which are consequences of reduced moisture from the gland. The skin collapse giving access to compression on the bone and continuous damage to the foot muscles result to ulceration and sometimes with gangrene which is the vilest case of peripheral neuropathy resulting to amputation. (Clayton and Elasy, 2009).
A review of Ade’s medications, I will focus on his current medication in line with UK recommended diabetes medication.
Ade confirmed that he has not been consistence with taking his medication because he cannot afford continuous over counter purchase of the drug and in most cases, he adheres to his daily herbal root drink till he can afford to buy his prescribed drugs. His current prescription is metformin (500mg once daily), glibenclamide (7.5mg once daily) and aspirin (75mg, once daily).
Most indigenous Nigerian will rather adhere to daily shots of traditional herbs as a curative path to their disease rather than accepting prescribed drug by their GP for long time management , health care provider constant education on diabetes may help increase patients’ awareness and adherence to medication for improved evidence-based practice among them. (Uloko et. al.,2012).
The efficient quality brand of metformin in Nigeria, Glucophage is pricy and quite unaffordable for low income patient causing a struggle in the management of their disease conditions as a lot medical facility do not have the required guidelines to facilitate the knowledge most people living with diabetes however, this is not a problem among the wealthy people of the same country because of their ability to access quality healthcare and lifestyle management outside the coast of Nigeria (Bosun-Arije et al., 2019).
This confirms the information of the In Africa, the International Diabetes Federation African region that best clinical practise is not offered to diagnosed type2 diabetes patients (IDF, 2017).
Affluent people can affordably access good healthcare that enables them to manage their illness well. Poor people, however, struggle to gain access to effective treatment. It has been noted that many health settings lack effective policies that can facilitate the empowerment of individuals diagnosed with the condition, especially for people with limited income (Chan, 2016). In Africa, the International Diabetes Federation African region warned that optimal management was not being delivered to most patients diagnosed with T2DM in clinical practice
Metformin due to its wide endorsement and favoured antidiabetic drug by present current clinical guidelines (Ogbonna and Ezenduka 2014, NICE, 2010) has made it the first line of diabetes management drug in Nigeria and it is highly recommended along with lifestyle adjustment for both obese and non-obese diabetic patients.
Adegbola et al., (2017) reported in their study that the effect of metformin for diabetes management supersedes other antihyperglycemic drugs in reducing the problem of macrovascular- and microvascular diseases associated with advance diabetic patient.
Hemmingsen et al., (2014) in comparing the use of either sulfonylurea or metformin as single therapy in the management of type 2 diabetes, metformin was considered widely acceptable as there is no link of hypoglycaemia and not also not associated with weight gain.