Hyperglycemia may be due to insufficient insulin or poor response to insulin. Hyperglycemia may also be present with altered metabolism of lipids, carbohydrates, and proteins with increased risk of cardiovascular diseases.[¹]

Sedentary life style is a major cause of obesity that is a factor for diabetes mellitus in middle-age population.[²] Disorder of lipid metabolism and hypertension may be seen in the diabetic patients.[³] It is an admitted fact that the larger the waist belt, the shorter will be the life and vice versa. If not treated, the hyperglycemia may go onto fulminant diabetes mellitus and its effects on end organ damage like kidneys, eyes, heart, and brain can be fatal in type II diabetes mellitus.[^{4, 5}] The prevalence of diabetes mellitus is attributed to ethnicity while living in the same environment.[⁶] However, western life style accelerates its prevalence. Diabetes mellitus can be better managed with control on diet, though pharmacotherapy is one the best option once the disease goes out of control.[⁷] However, poly-pharmacy carries risks of drug interactions and adverse drug reactions.[⁸] Hence, we analyzed retrospectively the treatment charts of the patients for possible pharmacotherapy therapy-based problems.

As mentioned in Table 1, total 856 diabetic patients were admitted in the hospitals. Therapy was advised for control of their major illness i.e. hyperglycemia with concurrent cases like diabetic foot. It is evident that to 69.84% cases (n= 600, type I and type II inclusive), insulin therapy was advised. In certain cases, combination therapy of insulin and oral hypoglycemics (60.3 %, n= 516) were tried to control hyperglycemia. According to Table 1, among the prescribed oral hypoglycemics, metformen was most frequently (39.68 %, n= 360) prescribed. The oral hypoglycemics were of the order: metformen (39.68%) > glibenclamide (12.69%) > glimeperide (9.52 %) > pregabaline (7.93%) > gilipizide (4.76%) = gliclazide (4.76%) > tolbutamide (1.58%). Interestingly, the hyperglycemia was controlled with insulin therapy. But there was no correlation of blood glucose levels with insulin therapy that lead to hypoglycemia that was observed in 12% of the reported cases (data not shown). The main reason of negligence, in this regard, was due to the fact that the laboratory reports were received at 11:00 am and the patients had to receive their advised insulin therapy in the morning between 8:00 and 9:00 am that reflects poor correlation of the therapy with patients’ biochemical tests. In Table 1, as per reported medical literature, potential drug interactions are listed that required interventions but were not intervened. To most of the patients (41.66%, n= 357), insulin therapy was advised in combination with glucocorticoides, thiazides diuretics, and propranolol. Insulin and glucocorticoids combination increases hyperglycemia and decreases affinity of tissue receptors response to insulin.[^{11, 12}] It is noteworthy that thiazide diuretics decreases the sensitivity of insulin to its receptors and of course its secretion as well.[^{13, 14}] Metformen was prescribed to a renally impaired patient (a contrindications of metformen).[¹⁵] Combination of beta blockers (BBs) can be dangerous not only in a sense that BBs decrease the secretions of insulin from the islets of Langerhans but also mask the symptoms of reflex tachycardia that is regarded as a vital force (to me personally) in combating hypoglycemia and can be fatal.[¹⁶] Combination of aspirin and heparin combination have reported with GIT bleeding[¹⁷] that was not intervened as suggested in Table 1. The higher incidence of diabetic foot patients was in the mean age of 57±3.4 years (data not shown). Hence, more care should be exercised in patients with mean age 57±3.4 years and insulin regimen should be incorporated for the management of hyperglycemia to help prevent them from complication of diabetic foot rather than to wait and let the patient goes on to complications.[^{19, 20}] In this regard, a comprehensive awareness program is necessary to change the mind set of diabetic patients about the insulin therapy and give them awareness about diabetic foot as a complication. Having done this accordingly, as stated earlier, the patients will keep on taking advised insulin therapy and they will not go onto diabetic foot, the major cause of hospitalization.[^{19, 20}] All the events related to pharmacotherapy problems are summarized in Table 2 in light of the algorithm described by Yarborough PC.[⁹] Out of the total patients, 11.11% could not take the prescribed drugs due to pharmaceuticalbased problems like poor acceptance to insulin syringe prick. The reported ADRs were diarrhea (7.69%), burning micturation, and weakness (2.0%). 41.66% of the cases carried potential risks of drug interactions and the most frequently encountered drug interactions are mentioned in Table 1. Self-explanatory mismatches are summarized in Table 2 that are 20.0% in the main drug therapy and 41.26% in the supportive drug therapy that lead to a high antibiotic number per patients (2.4/patient). To 6.6% of the cases, no relevant drug therapy was prescribed for indications such as hypertension, hepatitis, diarrhea, fatigue, and burning feet syndrome and stress. This reflects poor patient’s health care system that requires improvements in light of the practice of rational therapeutics. Hence, it is imperative to improve the practices of therapeutics by providing our health professionals a patient’s based learning rather than to practice in routine.[²¹] Poly-pharmacy leads to many ADRs that can be anticipated by interdisciplinary integration of disciplines such as medicine, pharmacy, and other health professions for the promotion of practice of rational therapeutics. A “medication review team”[²²] including pharmacists and physicians may be constituted throughout the country to give concise recommendations and corrective measures for proper utilization of drugs.

Source of Support: Nil

Conflict of Interest: None declared

The author wants to thank the Chief executives and Chief pharmacists of the concerned Teaching Hospitals for providing an opportunity to the internees of Pharm-D Program of University of Malakand.