What approach should be taken for medication reconciliation in a patient with hypertension and diabetes type 2 on Norvasc (Amlodipine) and Metformin?

Medication Reconciliation HPI for Patient with HTN and Type 2 Diabetes on Norvasc and Metformin

For this patient on amlodipine (Norvasc) and metformin, verify current doses, assess adherence, check for contraindications (particularly metformin's renal function requirement of eGFR ≥30 mL/min/1.73 m²), and evaluate whether additional cardioprotective agents are indicated based on cardiovascular risk stratification. 1, 2

Essential Elements to Document

Current Medication Verification

• Amlodipine dose and frequency: Confirm the patient is taking the prescribed dose (typically 5-10 mg daily) and assess timing of administration 3
• Metformin dose and formulation: Document whether immediate-release or extended-release, total daily dose (typically 750-2000 mg daily), and whether taken with meals to minimize gastrointestinal side effects 1, 2
• Adherence assessment: Specifically ask about missed doses, barriers to taking medications (cost, side effects, complexity), and whether prescriptions are being filled regularly 1

Critical Safety Parameters to Assess

Renal function status: Metformin requires eGFR ≥30 mL/min/1.73 m² for safe use; document most recent creatinine and eGFR, as this is the primary contraindication concern 1, 2

Metformin-specific contraindications: Ask about and document:

• History of lactic acidosis 2
• Liver disease or alcohol abuse (increases lactic acidosis risk) 1, 2
• Heart failure requiring pharmacologic treatment 2
• Recent or planned procedures requiring contrast dye or NPO status 2

Amlodipine tolerability: Document presence or absence of peripheral edema (occurs in ~6% of patients), dizziness (3%), or hypotension (2%) 3, 4

Glycemic and Blood Pressure Control Assessment

• Current HbA1c and blood glucose patterns: Document most recent HbA1c to determine if current regimen is adequate (target typically <7% for most patients) 1
• Blood pressure readings: Document recent BP values to assess control (target <130/80 mmHg for patients with diabetes) 1, 4
• Hypoglycemia history: While metformin monotherapy has minimal hypoglycemia risk (0.5-2.2%), document any episodes 1, 5

Comorbidity Screening for Treatment Intensification

The 2022 KDIGO guidelines mandate screening for conditions that would trigger addition of cardioprotective agents beyond metformin and amlodipine: 1

• Established atherosclerotic cardiovascular disease (ASCVD): History of MI, stroke, peripheral arterial disease, or coronary revascularization 1
• Heart failure: Any history or current symptoms of HF, as this mandates SGLT2 inhibitor consideration 1
• Chronic kidney disease: Document albuminuria status (urine albumin-to-creatinine ratio) and eGFR, as albuminuria ≥30 mg/g indicates need for RAS blockade and potentially SGLT2 inhibitor 1
• High cardiovascular risk indicators: Age, smoking status, family history of premature CVD 1

Medication Gaps to Address

If patient has established ASCVD, heart failure, or CKD with albuminuria, current regimen is inadequate: 1

• SGLT2 inhibitor should be added (can be initiated if eGFR ≥20 mL/min/1.73 m²) 1
• GLP-1 receptor agonist should be considered if SGLT2 inhibitor insufficient or not tolerated 1
• Statin therapy is recommended for all patients with diabetes and CKD 1

For hypertension management with albuminuria present: RAS blockade (ACE inhibitor or ARB) should be first-line rather than amlodipine alone 1

Adverse Effects Monitoring

• Metformin gastrointestinal effects: Document nausea, diarrhea, or abdominal discomfort (common, can be minimized by taking with food and gradual titration) 1, 2
• Vitamin B12 deficiency: Consider checking B12 level if patient has been on metformin long-term, especially if anemia or peripheral neuropathy present 1
• Amlodipine-related edema: Specifically examine for and document lower extremity edema 3, 4

Lifestyle Modification Documentation

• Diet and exercise adherence: Document current dietary patterns, physical activity level, and weight trends, as these remain foundational 1
• Weight changes: Both medications can affect weight (metformin may cause modest weight loss, amlodipine is weight-neutral) 1, 3
• Smoking status: Critical for cardiovascular risk stratification 1

Common Pitfalls to Avoid

Failing to check renal function before continuing metformin: This is the most critical safety issue, as declining renal function increases lactic acidosis risk 1, 2

Missing opportunities for cardioprotective therapy intensification: If patient has ASCVD, HF, or CKD with albuminuria and is not on SGLT2 inhibitor or GLP-1 RA, this represents suboptimal care based on current guidelines 1

Not addressing albuminuria with RAS blockade: Amlodipine alone is insufficient for hypertension management when albuminuria is present; ACE inhibitor or ARB should be first-line 1

Overlooking medication access barriers: Document insurance coverage and out-of-pocket costs, as these significantly impact adherence 1