9. Diabetes Year 2

7/21/2019 9. Diabetes Year 2

http://slidepdf.com/reader/full/9-diabetes-year-2 1/36

Pharmacist’sRole in the

Management of

Dipa Kamdar



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



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



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



“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”



Complications



In the UK…..



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



Management of Diabetes

Advice regardinglifestyle changes

Diet Exercise

Smoking

Alcohol

Driving

Regular checks



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



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



Insulin

Devices



Advantages Disadvantages

Vial +

syringe

Pre-filled

pens

Penfill

cartridges

Insulin

Pump



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



Insulin – Counsellingon Lifestyle

DrivingHolidays

and travel

Ramadan

Alcohol

Shiftwork Insurance

Sportsandexercise



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



Future Technologies in Monitoring

Implantable long

term continuousglucose monitoring

sensor

Light sensor

Contact lens(microchip)

Tattoo (sensors)

Breathalyser

Saliva

Earlobe Sensor



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.



NICE Guidelines



Drug Therapy

Continued…



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



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



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




Nephropathy

Minimised by good glucose + BP control

Characterised by microalbuminaemia

Worsens to proteinuria

ACE inhibitor slows progression

Keeping well hydrated




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.



Complications

Hypoglycaemia

Symptomatic if glucose <2.2mmol/L



Management of Hypoglycaemia

Glucose 10-20g orally

Snack (carbohydrate)

Hypo withunconsciousness =

emergencyGlucagon

If ineffective

Glucose IVinfusion

10 mins



Diabetic Ketoacidosis

IV infusion soluble insulin

Fluids

Potassium

State of uncontrolled catabolismassociated with insulin deficiency(usually type 1)



Role of Pharmacist

Prevention

Identificationand diagnosis

Initial assessmentand management

Ongoingcare

Preventing or

delayingcomplications



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



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?



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



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

9. Diabetes Year 2

Documents

Transcript of 9. Diabetes Year 2