DIABETES
polyuria, and unexplained weight loss in T1), diabetes may be confi rmed by:
• A random venous plasma glucose concentration of ≥11.1 mmol/L, or;
• A fasting plasma glucose level of ≥7 mmol/L, or;
• A plasma glucose level of ≥11.1 mmol/L two hours after the administration of 75g of oral anhydrous glucose (known as the Oral Glucose Tolerance Test (OGTT))
Some diagnostic documents indicate the use of HbA1c as a marker, however, the use of this test is unsuitable in a number of situations, which are outlined in Box 1.
Box 1. Patient states which prevent the use of HbA1c levels
as a diagnostic criteria3 . • All children and young people
• Patients who have had the symptoms of diabetes for less that 2 months
• High risk patients who are acutely ill
• Patients taking medications causative of rapid glucose fl uctuations (e.g. steroids, various antipsychotics)
• Patients with acute pancreatic damage
• Pregnant patients
As such, it can be seen that the diagnosis of diabetes can indeed be a minefi eld, but pharmacists should ensure that they are aware of the tests which are routinely carried out, how to interpret the levels indicated by these tests, and critically, the symptomatic hallmarks of the condition which may indicate that a patient may be suffering from diabetes which is currently undiagnosed.
When diabetes is treated, it is important that the patient aims to maintain blood glucose at a level which is as normal as possible (i.e. equivalent to a person who does not have diabetes). As a result, pharmacists should be aware of these levels, and council newly-diagnosed patients on these, as appropriate. According to Diabetes UK, the current guide target levels are4
:
• Children with T1 diabetes: • 4-8 mmol/L before meals
• Less than 10 mmol/L two hours after a meal
• Adults with T1 diabetes: • 4-7 mmol/L before meals
• Less than 9 mmol/L two hours after a meal
• T2 Diabetes: • 4-7 mmol/L before meals
• Less than 8.5 mmol/L two hours after a meal
Due to the complex nature of the condition, target levels may vary somewhat on a patient-to-patient basis, with these being agreed between the patient and their diabetes care team. Pharmacists should be prepared to council patients on these differences, and able to explain why their target levels may differ to that within literature that they may have been provided with.
THE TREATMENT The treatment of diabetes is often complicated, and must be specifi cally tailored to the patient, with respect to the product or products used, and the doses of each of these preparations. As a result, it is not possible to delve fully into the treatment of diabetes within this article, and pharmacists are reminded that they should endeavour to keep their knowledge up to date with the latest prescribing guidance, and should also be aware of new products for diabetes control as they appear on the market. The use of resources such as the BNF, appropriate NICE guidance, and other diabetes- specifi c documentation are all very valuable to this end. Having this knowledge will allow pharmacists to react appropriately to patient queries, and continue to act as the expert on these medicines.
Due to the nature of T1 diabetes, the standard treatment is the use of insulin. The range of insulin products available to the patient can be overwhelming, ranging from short to long-acting products, through to insulins derived from animal sources or from recombinant human-based sources. When the delivery methods used for insulin administration are then factored into the mix, the area of T1 treatment becomes even more complex. Pharmacists must be aware of the use of these devices, from
standard syringes, various “pen”-type injectors, to autoinjectors and insulin pumps, and know how they are used, as the pharmacy will often be the fi rst port of call for patients who have either been started on their fi rst therapy, or have been switched to a new device. Again, this information can be gathered from various sources, including the manufacturer of the product, who may be able to supply placebo devices, which can signifi cantly assist with your patient counseling.
The treatment of T2 diabetes is as complex as that of T1, if not more, and is becoming more complex on a regular basis due to the emergence of next generation oral hypoglycaemics. The use of standard, commonplace drugs such as metformin and gliclazide is still the norm, and pharmacists should be aware when their use is appropriate (remembering to include a number of factors such as body weight, etc., into this consideration. However, the use of newer drugs such as thiazolidinediones (pioglitazone, rosiglitazone), Dipeptidyl peptidase-4 inhibitors (saxagliptin, sitagliptin), GLP-1 analogues (exenatide, liraglutide), and post-prandial glucose regulators (repaglinide, nateglinide) is also now becoming increasingly common, in line with the greater prevalence of the condition itself, and the need for greater control blood-glucose levels in order to prevent long-term complications5
.
Moreover, next-generation drugs are consistently fi nding space in the market for the treatment of diabetes, which more recently include drugs such as dapaglifl ozin (Forxiga) This drug, a sodium-glucose co-transporter 2 (SGLT2) inhibitor, functions by prevention of glucose reabsorption which is facilitated by the kidneys. Whilst these drugs have shown promise, and have been recommended in some restricted cases by NHS Scotland, the side effects of these new drugs must also be taken into consideration. For example, due to the mechanism of action of this drug, urinary tract infections are much more likely (particularly in women), in addition to other side effects commonly associated with these major drug groups, such as hypoglycaemia6
. Once again,
pharmacists should use the resources available to them to ensure they are aware of the prescribing guidance for these drugs, how they are used, and other appropriate information
that will assist them during clinical intervention, decision making within interprofessional teams, and patient counseling.
COUNSELLING POINTS In addition to the counseling of patients, newly diagnosed or otherwise, on the use of their treatments, how to use glucose testing apparatus, and the interpretation of the generated results, pharmacists must remain at the front and centre of health promotion for these patients, providing advice which can assist with the management of their ailment, whilst also potentially avoiding severe complications. Patients should be given advice on diet and exercise, and the intake of safe levels of glucose-containing products in order to maintain target blood-glucose levels. In addition patients should be counseled to carry the likes of glucose gel with them at all times (where appropriate), in the case of hypoglycaemic attack. In addition, pharmacists should be in the position to appropriately counsel diabetic patients on actions to take in various other medical situations. A good example of this are the general “sick day rules”, which should be followed should the patient be suffering from illnesses such as colds and fl u. Information on these particular counseling points can be found using great resources like the Diabetes UK website, and pharmacists should ensure that they are using these points of information to their fullest extent in order to provide their patient with a high level of professional care. •
REFERENCES
1 NHS Scotland. Scottish Diabetes Survey 2012. 2012; Available at: http://www.dia-
betesinscotland.org.uk/publications/sds%20 2012.pdf. Accessed 03/09, 2015. 2 NHS Scotland. The Scottish Diabetes Sur- vey 2013. 2013; Available at: http://www.
diabetesinscotland.org.uk/Publications/ SDS2013.pdf. Accessed 03/09, 2015. 3 Diabetes UK. Diagnostic criteria for diabetes. 2014; Available at: http://www.
diabetes.org.uk/About_us/What-we-say/ Diagnosis-prevention/New_diagnostic_crite- ria_for_diabetes/. Accessed 03/09, 2015. 4 Diabetes UK. Testing. 2014; Available at:
http://www.diabetes.org.uk/Guide-to- diabetes/Monitoring/Testing/. Accessed 03/09, 2015.
5 Department of Health, Social Services and Public Safety. COMPASS Therapeutic Notes on the Newer Drugs used in the Manage- ment of Type 2 Diabetes Mellitus. 2010; Available at:
https://www.nicpld.org/courses/COMPASS/ NewerDrugsType2Diabetes.pdf. Accessed 03/09, 2015.
6
diabetes.co.uk. SGLT2 Inhibitors Glifl ozins. 2015; Available at: http://www.
diabetes.co.uk/diabetes-medication/sglt2- inhibitors.html. Accessed 03/21, 2015.
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