By Jennalynn Fung, PharmD Candidate c/o 2025
Introduction
I’m a final year pharmacy student completing my Advanced Pharmacy Practice Rotations. I completed one of my ambulatory care pharmacy rotations at Crow/Northern Cheyenne Hospital in Crow Agency, Montana, which serves Native Americans. I had previously worked as a JRCOSTEP in summer of 2021 at the same site and sought to serve the community once again but on a more clinical level. During this rotation, I lead many patient visits for chronic conditions like diabetes, hypertension, hyperlipidemia, coagulative issues, and more.
Case Presentation
A 44-year-old national firefighter presented to the pharmacy clinic for medication management. He had no chief complaint, only presenting to the hospital to refill his medications in preparation of expected work-related travel for the next month. Upon evaluation, the patient had three major uncontrolled disease states which all required treatment.
Patient History
Medical History
- Type 2 Diabetes, diagnosed in 2021
- Hyperlipidemia, diagnosed in 2021
- Hypertension, diagnosed in 2023 – related to proteinuria
- Obesity – Class 1, Low risk
Medications
- Alogliptin 25 mg tab – 1 tab by mouth everyday
- Metformin 500mg XR tab – 2 tabs by mouth twice a day
- Rosuvastatin 20mg tab – 1 tab by mouth everyday
Allergies
- Ibuprofen allergy
Social History
- Patient works as a national firefighter which requires him to carry a 65-pound pack and hike several miles through mountainous terrain. He typically works 30 to 32 days at a time and returns home for 3 days at a time during the fire season. He reports that his job can be stressful depending on where and who he is working with, bringing up anecdotes of emergency situations where local and state level fire departments would not cooperate with the national level.
- While on the job, he may stay at a hotel, vehicle, or in the field depending on what is available. When at home, sleeps-in the first day back. On the second and third day, tries to get housework and other domestic responsibilities done, including picking up his medications. Mentions he doesn’t have time for an appointment with a provider.
- Patients says he drinks a lot of Gatorade, provided by his job, and eats what is available to him while on the road. This may be be grocery store or gas station food. He tries to watch YouTube videos to educate himself on diabetes and nutrition. Patient does not drink alcohol and does not mention exercising other than work. Reports trying to rest when back at home.
Family History
- Mentions that all individuals on his father’s side have high blood pressure and cardiovascular issues.
Physical Examination
Vital signs
- Heart rate: 86 beats per minute
- Blood pressure
- Late 2024: 135/88
- Early 2024: 135/88
- Early 2023: 131/89
- Early 2023: 138/93
- Early 2022: 129/79
Height: 170 centimeters (5 foot 5 inches)
Weight: 94.9 kilograms (202.219 lb)
Body Mass Index (BMI): 32.77
O2: 97%
RS: 18/min
Temperature: 95.72 F (35.4 C)
General appearance
- Awake and fully able to converse, sitting in chair
- Appeared calm, comfortable, asymptomatic other than expressed increased thirst and frequent urination
Laboratory Evaluation
| GOAL | < 7% | 80-130 F <180 PP | < 70 | > 40 | < 150 |
| Year | A1C | Glucose | LDL | HDL | TRIG |
| 2024 | 12.3 | 564 | 208 | 44 | 184 |
| 2023 | 185 | 45 | 245 | ||
| 2023 | 11.3 | 278 | |||
| 2022 | 13.7 | 346 | |||
| 2022 | 15.1 | 387 | |||
| 2021 | 146 | 45 | 576 | ||
| 2021 | 6.3 | 134 | 128 | 54 | 80 |
Counseling points and patient-provider conversation
New lab results did not arrive until after discussing treatment options based on the most recent available labs with the patient. Through the discussion, the patient confirmed that the last time he had received his medications was nearly 4 months prior. His medication non-adherence placed him at risk of his conditions progressing and worsening. He was open to restarting his previous medications, but also open to revising therapy as the pharmacist saw fit.
In previous visits with providers, he had expressed disinterest in injectable therapy.
During this clinic visit, he explained that he tried to manage his diseases without medication in the beginning. He said he was successful and lowered his A1C greatly. He explained he has been teaching himself about diabetes, diet and nutrition, and blood glucose through watching YouTube videos. He explained that he sometimes feels his blood glucose levels are low, and that he carries glucose with him to get his levels back up.
Based on guidelines, many different pharmacotherapy options were suggested for either initiation or discontinuation.
Recommended by Diabetes guidelines:
- Metformin – patient was OK with continuing this. Explained the process of max dosing and advised him to take it with food.
- Insulin – due to the patient’s glucose levels exceeding 300 and an A1C exceeding 10, it would be beneficial to initiate this. However, he explained that storing and refrigerating the insulin would be difficult. He also was not confident in his ability to do follow-up within two weeks over the phone with the pharmacy clinic.
- Ozempic – highly recommended by guidelines due to ability to help manage diabetes and other comorbidities simultaneously. He liked that it was a once weekly dose, but was not confident in his ability to store at room temperature during the fire season.
- Empagliflozin – can help significantly lower both the A1C and glucose by removing sugar from the blood and pushing it out through the urine. However, had to explain to him that with an A1C over 10, his body was already peeing out a lot of sugar. Thus, with the addition of this medication, glucose in urine would be even higher and would increase risk of developing urinary and genital infections. He was okay with this and decided it was worth trying. He was directed to call the pharmacy clinic phone number if any symptoms appeared, and he would need to see a provider if he developed an infection.
Not recommended by Diabetes guidelines:
- Alogliptin – won’t do much for his A1C. Pharmacist’s counseling point was that “it will be like a drop in the bucket, only impact by like 0.8.”
During care at the clinic, his blood pressure was taken. It was 147/99 upon first measurement; then, remeasured to be 137/93. Both values are still above goal, indicating a need for pharmacotherapy.
Recommended by Hypertension guidelines:
- ACE Inhibitor/Angiotensin Receptor Blocker (ARB) + Dihydropyridine-Calcium Channel Blocker (DHP-CCB)
- Lisinopril (ACE Inhibitor) would be beneficial to start at a low dose, then titrate up to reach the goal. Lisinopril 10mg is appropriate.
Counseled on:
- Hypoglycemia – symptoms and ways to combat when levels are below 70
- Pseudohypoglycemia – the importance of understanding when blood sugar may feel low, but are not actually low
- Hyperglycemia – more than 125 FBG, more than 180 PPBG
- What to eat and how much carbs to eat (plate visual)
- Blood glucose logs to record at least 3 mornings for fasting, and 3 nights for post-prandial / before bedtime
- Importance of adherence to prevent progression of disease
- For diabetes, preventing diabetic ketoacidosis, retinopathy, neuropathy, diabetic foot infections and more
- For hypertension and hyperlipidemia, preventing cardiovascular disease
Further Developments
When labs arrived, this prompted immediate treatment. His LDL came back at 208 mg/dl, prompting the reinitiation of rosuvastatin that prevents the creation of cholesterol by selectively and competitively inhibiting HMG-CoA reductase.
His A1C and glucose were 12.3 and 564, respectively, requiring insulin. 5 units of insulin Aspart were administered subcutaneously, then glucose was remeasured after 15 minutes. The blood glucose level dropped from 564 to 394.
It was important to note that the patient was shocked to learn his sugar levels were above 500. He had mentioned during the beginning of the clinic visit that he has been feeling low. However, with a level above 500, it is extremely unlikely that it was true hypoglycemia, indicating that he might not truly understand how and when to recognize a real low blood sugar for his body, and may have underestimated his ability to manage the diseases without medicine.
Outcome (Treatment and Plan)
In clinic: Initiated Insulin Aspart 5 units SQ
Outpatient:
Restarted Metformin XR 500mg – tapering according to guidelines, starting with 500mg XR QD for 1 week, then increasing by 500mg every week until a max total dose of 2000 mg/day.
Restarted Rosuvastatin 20mg
Initiated Lisinopril 10mg
Fingerstick testing supplies – freestyle lancet, lite (glucose) test strip, and glucose monitor
Patient will return to hospital to see a provider and pharmacist at the end of 2024 for updated diabetes and hyperlipidemia labs, as well as monitoring potential adverse effects from the medications (such as potassium changes due to lisinopril use, or the need for increasing dosages due to not reaching set lab goals).
Barriers and Social Determinants of Health
The patient’s lifestyle and work require constant travel and long periods away from home, making it difficult to adhere to consistent medication schedules, access to care by providers and pharmacists, and difficulty in storing his medications. His housing is unstable; stay and temporary lodging can also contribute to lack of access to healthcare or medications.
His diet being influenced by convenience rather than health can also contribute to worsening of his conditions. The stress of fighting fires and working in teams can also be a factor. His work being physically demanding may also lead him to believe that his level of exercise is sufficient to manage his diseases without medicine. Being involved in the firefighter work culture may also contribute to his belief that he is tough and can combat problems on his own without any help.
National health policy and work policies may make it more difficult to obtain care. The availability of telehealth and nationwide pharmacy networks could be scarce depending on where he is stationed for work. Firefighters who declare insulin dependency are required to pass more physical examinations to work on the front lines, which may discourage a patient from taking insulin even if it helps them manage their conditions, because it has the possibility of affecting his income.
In addition, individual level social cognition and cognitive control processes can play a part in how he interprets the disease state and its ability to be managed without medication. Although he states he was previously an EMT, he mentioned he switched careers due to too many examinations as an EMT. Thus, he likely has some health literacy but may not exercise or strengthen his medical vocabulary regularly. He attempts to educate himself about diabetes and nutrition by watching YouTube videos, but the accuracy and quality of that information is not verified. His belief in managing diabetes through diet alone may stem from misconceptions about the severity of his condition or the necessary role of medications in treatment. His understanding of hypoglycemia versus pseudo hypoglycemia may also be lacking. Although he states he is willing to restart medications, his inability to regularly follow up with his providers and his inconsistent medication use suggest that his work-life balance may impair his ability to plan and execute long term health strategies.
There is also a question of the kind of support system he has at home; he may have a girlfriend, but unknown whether he has other ties to the community. Also remaining a question is whether his ability to manage his conditions improves after the fire season ends.
Discussions
In rural or underserved areas, patients like this firefighter, who are constantly on the move and unable to access regular healthcare, often fall through the cracks of the healthcare system. Without consistent follow-ups or the ability to access specialists frequently, many patients may struggle to manage chronic conditions, leading to worsened outcomes over time. This lack of access could contribute to higher rates of diabetes-related complications such as diabetic ketoacidosis, neuropathy, or cardiovascular disease.
Due to limited access to regular healthcare, it’s difficult to adhere to the ideal management of chronic conditions like diabetes, hypertension and hyperlipidemia. This patient, with an A1C of 12.3%, glucose of 564 mg/dL, and LDL of 208 mg/dL, would typically require more immediate follow-ups and lab monitoring every three months. However, the constraints of his lifestyle make this approach impractical. These situations emphasize the value of pharmacists in adapting rigid clinical guidelines to real-world conditions, where traditional care models may not always apply.
Pharmacists, as the drug experts, play a vital role in interpreting and applying these guidelines in a flexible manner, especially when patients don’t fit neatly into standard protocols. In this case, the pharmacist recognized the urgency of the patient’s uncontrolled diabetes and initiated insulin therapy with 5 units of insulin Aspart in the clinic, alongside restarting metformin and adding rosuvastatin and lisinopril. Ideally, the patient would need close monitoring, particularly with insulin initiation, including a follow-up within two weeks. But given the patient’s nomadic lifestyle and challenges in accessing care, the pharmacist had to balance immediate intervention with the practicality of long-term adherence.
Recognizing that regular insulin use could be problematic due to the patient’s limited ability to store the medication while on the road, the pharmacist considered other options, such as empagliflozin, which could offer glycemic control without the strict storage and administration requirements of insulin. This decision reflects the pharmacist’s ability to apply clinical knowledge in a patient-centered way, adapting the rigid framework of care guidelines to suit the patient’s unique circumstances. Flexibility is key in such cases, and the pharmacist’s expertise allows for tailored solutions that still prioritize patient safety and optimal outcomes.
Beyond medication management, the pharmacist also plays a crucial role in educating patients about their condition and treatment. In this case, the patient received important counseling on the recognition of hypoglycemia, an especially pertinent concern when insulin is introduced. The pharmacist also emphasized the long-term risks of uncontrolled diabetes, which could impact the patient’s overall health, work, and lifestyle if not properly addressed. While a follow-up appointment is scheduled for the end of 2024, the pharmacist’s intervention ensures that the patient has a treatment plan in place that can function, even under less-than-ideal circumstances.
In summary, pharmacists are invaluable in managing complex patients who do not fit neatly into clinical guidelines. Through their deep understanding of pharmacotherapy and their ability to adjust treatment plans in a patient-centric manner, they help optimize care even when perfect management isn’t possible. This case illustrates the importance of pharmacists in rural or underserved areas, where healthcare access is limited, and clinical flexibility is often required to meet patients where they are.
References
- American Diabetes Association. Firefighters and Diabetes Discrimination. American Diabetes Association. https://diabetes.org/advocacy/know-your-rights/fire-fighters-and-diabetes-discrimination. Published 2024. Accessed October 1, 2024.
- American Diabetes Association. Standards of Medical Care in Diabetes—2024. Diabetes Care. 2024;47(Suppl 1). doi:10.2337/dc24-SINT.
- Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(25). doi:10.1161/CIR.0000000000000625.
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6).doi:10.1161/HYP.0000000000000065.
- Whitman A, De Lew N, Chappel A, et al.. Addressing Social Determinants of Health: Examples of Successful Evidence-Based Strategies and Current Federal Efforts. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. April 2022. Report No. HP-2022-12.
