9. diabetes year 2
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diabetesyear 2TRANSCRIPT
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Pharmacist’sRole in the
Management of
Dipa Kamdar
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Learning Objectives Students should be able to:
Describe the prevalence of diabetes
Discuss the management of diabetes
Discuss the management of diabetic
complications
Discuss the role of a pharmacist in the
management of diabetes
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Diabetes Mellitus (DM)DM is the name given to a group of disorders wherethe circulating levels of the hormone insulin are
insufficient to maintain blood glucoseconcentrations within the normal range (4-7mmol/l*) *varies in literature
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3.7 million people live with Type 1 and Type 2
diabetes and 7 million people at risk of developing Type 2 diabetes in the UK
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“Around 10 per cent of NHS spending goes on
diabetes and its complications; this equates to£10 billion per year or £1 million an hour”
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Complications
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In the UK…..
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Standard 4 of NSF for diabetesKey recommendations
a) Improve blood glucose control
Drug choice/monitoring
b) Control hypertension
Reduce CVD/retinopathy/nephropathy
c) Reduce raised cholesterol levels
Give Statin + aspirin (2o
prevention)d) Encourage smoking cessation
NRT; Champix
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Management of Diabetes
Advice regardinglifestyle changes
Diet Exercise
Smoking
Alcohol
Driving
Regular checks
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Insulin Insulin is first line treatment for:
T1DM
T2DM when other methods havefailed to achieve good control,
Temporarily in the presence of
intercurrent illness or peri-operatively
In pregnant women with type 2diabetes when diet alone fails
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Types of Insulin
Short-acting
E.g.____________________________________________
Immediate acting
Human insulin analogues e.g.___________________
Intermediate
E.g.________________________________________
Long acting
E.g.________________________________________
Regimens Once daily + immediate acting
Biphasic x bd
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Insulin
Devices
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Advantages Disadvantages
Vial +
syringe
Pre-filled
pens
Penfill
cartridges
Insulin
Pump
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Insulin - Counselling
The following information on insulin administration should be
provided to a person with type 1 diabetes and to their familyor carers:
Insulin absorption — to be aware of the factors
influencing insulin absorption which can have an effect
on blood glucose control Injection sites — to ensure that the appropriate sites are
used for injecting insulin
Injection technique — to ensure that insulin is injectedcorrectly
Injection site rotation — to prevent lipohypertrophy
Timing of injection — to optimize glycaemic control
Self injecting — to support parents and young childrenusing self-injecting insulin
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Insulin – Counsellingon Lifestyle
DrivingHolidays
and travel
Ramadan
Alcohol
Shiftwork Insurance
Sportsandexercise
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Monitoring
Finger-prick
blood sample
Urine testing
Glucose Ketones
Microalbuminurea
Hospital testing
Glycosylated haemoglobin (HbA1c)
6.5–7.5% (48–59 mmol/mol) or less (reference range4–6% or 20–42 mmol/mol)
Insulin Passport
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Future Technologies in Monitoring
Implantable long
term continuousglucose monitoring
sensor
Light sensor
Contact lens(microchip)
Tattoo (sensors)
Breathalyser
Saliva
Earlobe Sensor
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Oral Antidiabetic Drugs
Used for T2DM (if not controlled by diet for
3 months)
NICE Guidelines Pathway for T2DM Treatment
Metformin first-line
Unless C/I, not tolerated etc.
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NICE Guidelines
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Drug Therapy
Continued…
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Dual Therapy
Metformin + Sulphonylurea
Or if sulphonylurea is C/I or causes severe hypoglycaemia,
try… DPP-4 inhibitor (sitagliptin, vildagliptin)
Thiazolidinedione (pioglitazone)
Canagliflozin
Dapagliflozin
Liraglutide Exenatide
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Control of
hypertensionNot all drugs are appropriate
Beta blockers in general should be avoided
Mask some symptoms of hypoglycaemia
Diuretics used with caution Hypokalaemia can impair insulin release and
worsen glucose tolerance
ACE inhibitors usually drug of choice
Especially in presence of proteinuria
Slow progress of renal complications even inabsence of IHD or raised BP
Useful in presence of heart failure
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Reducing complications
Retinopathy
Major cause of blindness
Regular eye tests
Can be managed withlaser treatment
Good glucose and BPcontrol
Refer to optometrist or ophthalmic optician
Diabetics get free eye tests
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Reducing complications
Nephropathy
Minimised by good glucose + BP control
Characterised by microalbuminaemia
Worsens to proteinuria
ACE inhibitor slows progression
Keeping well hydrated
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Reducing complications
Peripheral Vascular Disease &Neuropathy
Provide advice on good basic footcare, avoid narrow fitting, tightshoes, etc.
Keep toenails well trimmed, cutstraight across, etc.
Use request for foot care productsas ‘cue’
Seek attention ofchiropodist/podiatrist if appropriate
Warn of danger signs e.g. pins &needles
Get cuts, burns on feet treated
Watch for fungal infections, etc.
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Complications
Hypoglycaemia
Symptomatic if glucose <2.2mmol/L
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Management of Hypoglycaemia
Glucose 10-20g orally
Snack (carbohydrate)
Hypo withunconsciousness =
emergencyGlucagon
If ineffective
Glucose IVinfusion
10 mins
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Diabetic Ketoacidosis
IV infusion soluble insulin
Fluids
Potassium
State of uncontrolled catabolismassociated with insulin deficiency(usually type 1)
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Role of Pharmacist
Prevention
Identificationand diagnosis
Initial assessmentand management
Ongoingcare
Preventing or
delayingcomplications
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Screening in the
community
NHS HealthCheck
Aged 40-74years
If you exhibit
symptoms ofdiabetes e.g.Lethargy,polyuria, thirst
If you havemultiple risk factors for
diabetes e.g.Overweight,family history,ethnicity
• Questionnaire +/- finger prick blood glucose test
• If positive, referral to GP
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Medicines
Optimisation
All appropriate drugs
prescribed? e.g. statin, ACEI
Best choice of anti-diabetic agents?
Correct dosage regime?
Compliance with regime?
Complications optimally managed?
Education e.g. hypos, when to seek help?
Insulin
Dispensed correct insulin?
Storage?
Most appropriate device?
Appropriate test strips & monitors? Diary?
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Summary
Describe the prevalence of diabetes
Discuss the management of diabetes
Discuss the management of diabetic complications
Discuss the role of a pharmacist in the management
of diabetes http://video.novonordisk.com/video/10296136/the-
challenges-of-living-with-diabetes
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References
BNF – latest edition
Clinical Biochemistry – Allan Caw et al.
Saunder’s Pocket Essentials of Clinical Medicine – Allan Ballinger andStephen Patchett
http://www.nice.org.uk/nicemedia/pdf/CG66FullGuideline0509.pdf
www.diabetes.org.uk https://www.diabetes.org.uk/upload/Professionals/Publications/Winter%20
2012/MedicineDigest-winter2012.pdf
http://www.publications.parliament.uk/pa/cm201213/cmselect/cmpubac
c/289/289we02.htm
https://www.gov.uk/government/uploads/system/uploads/attachment_d
ata/file/198836/National_Service_Framework_for_Diabetes.pdf
Pearson, T. (2010) Practical Aspects of Insulin Pen Devices. Journal ofDiabetes Science and Technology. 4(3): 522-531.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901027/
http://cks.nice.org.uk/insulin-therapy-in-type-1-diabetes#!scenario