Metformin, a Blood Pressure Log, and a Patient Who Stopped Taking Her Medicine
Rosa, 58, has type 2 diabetes and reads English at about a fourth-grade level. She picks up a new bottle of metformin 500 mg tablets. The label says: "Take 1 tablet by mouth twice daily with meals." The bottle contains 60 tablets. She also takes lisinopril 10 mg once daily for blood pressure. In her bag is a home blood pressure log: 148/92, 152/90, 145/94, 150/96, 146/92 over five days. She tells the pharmacy aide, "I stopped the sugar pill two weeks ago. It made my stomach sick, and I felt dizzy when I stood up at church." She lives alone, takes the bus, and has a pill organizer with morning and evening compartments.
1. If Rosa takes the metformin as written, how long will the bottle last? What should the aide check before responding to the dizziness?
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The bottle: 500 mg twice daily means 2 tablets per day. 60 tablets ÷ 2 = 30 days. This is worth saying out loud, because a patient who reads "60 tablets" may assume two months and run out early, or ration the doses.
Before responding to the dizziness, the aide should establish:
- Is the lisinopril new, or was the dose changed recently? A new or increased blood pressure medicine is a common reason for feeling lightheaded on standing.
- Is she eating and drinking normally? She has been skipping a medicine because of stomach upset, which often means she is also eating less.
- Is she taking anything else - over-the-counter cold medicine, pain relievers, or a neighbor's pills?
- Is the dizziness only on standing, or also at rest? Did she actually faint, or come close?
The aide should not diagnose or suggest a dose change. The job is to gather these facts accurately and route them to the pharmacist, who can decide whether the prescriber needs a call today.
2. Rosa stopped the metformin because of stomach upset. What is the right response, and what is wrong with simply saying "just take it with food"?
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Right response:
- Acknowledge it. She reported a real side effect and made a decision; being dismissed is how patients stop telling you things.
- Explain that stomach upset is a common early effect for many people and often eases, but that she is the one who knows how bad it was.
- Tell her clearly: do not restart or permanently stop on her own - call the prescriber. There may be options, such as a different form of the same medicine or a change in how it is taken.
- Offer to help her make the call today, while she is in the pharmacy, and write down what the prescriber says.
Why "just take it with food" fails:
- She already knows the label says "with meals," so the instruction adds nothing new and implies she did it wrong.
- It does not address two weeks of missed doses, which the prescriber needs to know about.
- It ignores the dizziness entirely and may push her to take a medicine while feeling faint.
- It is a diagnosis by slogan. The pharmacist, not the aide, should advise on how to restart.
3. Sort Rosa's complaints into "handle today" and "call 911 now." Then write what you would say to her in plain language to check that she understands the plan.
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Handle today, with the prescriber: dizziness when standing, especially with a blood pressure medicine and a log showing readings mostly in the 145-152/90-96 range; and the two weeks of missed metformin. Neither is an emergency room trip if she is fully alert and feeling otherwise well, but both are same-day calls.
Call 911 (or go to the ER) now if: she faints or nearly faints, has chest pain or trouble breathing, has weakness or numbness on one side, has trouble speaking, becomes confused, or cannot keep fluids down.
Plain-language check, using teach-back rather than yes/no questions:
- "Show me how you would put a day of these pills in your organizer." She should put one metformin in the morning and one in the evening compartment, and the lisinopril once a day as directed.
- "What will you do if your stomach gets sick again?" She should say she will call the clinic and not just stop.
- "What will you do if you feel dizzy and then fall or almost fall?" She should say to sit down and call, and call 911 if it is worse than that.
- "When will you run out of the metformin?" She should connect 30 days with a refill date.
Write the clinic number and the refill date on the bottle in large print, and confirm she has a way to get back to the pharmacy by bus.