Plan
1. Uncontrolled painful diabetic neuropathy
■ Goals: Goals include improving pain symptoms and reaching patient-set pain goal of 6/10 within 4 to 6 weeks and improving function, quality of life and sleep within next month as treatment regimen is titrated appropriately based on patient's response. Minimize adverse drug reactions with treatment options.
■ Discontinue amitriptyline.
■ Refer to primary care provider to evaluate diabetes medication to achieve better blood glucose control (A1c Goal<>
■ Start slow titration of gabapentin 300 mg by mouth at bedtime for 1 week, then may increase to 300 mg by mouth two times daily for 1 week, then increase again to 300 mg by mouth three times daily. Titration to continue with goal dosing of gabapentin 600 mg by mouth three times daily to achieve optimal efficacy and tolerability. Monitor for signs of daytime sedation, confusion or peripheral oedema. Evaluate pain levels associated with diabetic peripheral neuropathy.
■ Encourage proper foot care: Daily examination of each foot to identify cracking, dryness or signs of infection. Stress importance of proper shoe selection.
2. Constipation: Adverse drug reaction secondary to amitriptyline
■ Goal: Improve symptoms with Bristol stool score of 4 (i.e., like a sausage or snake, smooth and soft), and achieve a daily regular bowel movement within the next 1 to 4 days without straining.
■ Initiate polyethylene glycol 3350: Mix 17 grams in 8 ounces of beverage, and drink once daily for 3 days; then use as needed when Bristol is less than 3 or other symptoms of constipation occur. Hold dose for loose stools. Provide education on Bristol stool chart. Encourage proper hydration and adequate dietary fibre via fruits and vegetables and stress the importance of doing as much exercise as can be tolerated.
3. Poorly controlled type 2 diabetes
■ Goal: Achieve haemoglobin A1c goal<>
■ Referral to diabetic education class for improvement of self-management skills.
■ Primary care provider (PCP) to evaluate diabetes medication for adjustment of oral medications to dual therapy to achieve better blood glucose control.
4. Controlled hypertension and dyslipidaemia: Continue current regimen.