transporter 2 in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion. It was estimated that 31,000 diabetics would be eligible for the recommended treatments: canagliflozin (Invokana), dapagliflozin (Forxiga) and empagliflozin (Jardiance). The three drugs were licensed for use alone or as part of combination therapy if a person can’t use metformin, sulphonylureas or pioglitazone, and diet and exercise alone isn’t controlling their blood glucose levels. By use of these drugs, it helps control blood sugar levels in those patients who for various reasons cannot take the more commonly prescribed medicines and also avoids the use of insulin, thus giving type 2 diabetics more management options. This was of significance as it is known that different people with type 2 diabetes respond favourably to different medications, therefore increasing the treatment options has a substantial impact on the quality of life of some patients, meaning their condition remains stable for longer.

The contribution that a pharmacist and their teams can make to the care of diabetic patients is well established, and there are various ways in which they can do this. By focusing on five key points in the patient’s journey it may have numerous benefits, such as maximising the potential from their therapy, alleviating symptoms and minimising the risk of long term complications:

1. Prevention – Prevention is always more effective than treatment, and therefore pharmacists and their staff have a role to play in identifying individuals at risk of developing diabetes (weight, family history, race, age, etc.) offering them lifestyle advice and appropriate intervention. There is currently thought to be 500,000 patients at high risk of developing the condition in Scotland.

2. Identification and diagnosis - Early diagnosis of diabetes can significantly reduce the risk of developing complications, as it allows people to receive the support they need to manage their condition, as there is an estimated 45,000 living with undiagnosed Type 2 diabetes in the region. Community pharmacy has an opportunity to proactively identify people with diabetes within the community setting with appropriate onward referral to the GP and other


healthcare professionals, where appropriate.

3. Initial assessment and

management - Pharmacy can offer more support to people in the early stages of taking a new course of medicines to treat a long-term condition, which may be utilised through the medicine use review service (MUR). Patient education is a valuable area in which pharmacists can become involved as if people are aware of the implications of having diabetes it will empower them to take control of their condition. It is recommended to engage patients with aspects such as what diabetes actually is, how to manage the condition, what the complications of diabetes are and how they can be prevented, and how diabetes can impact on life, eg, driving regulations and insulin.

4. Ongoing care - Most of the issues relevant to providing support to a person newly diagnosed with diabetes continue to be relevant throughout the management of their long-term condition. While remarkable progress has been made in the pharmacological management of diabetes over the past century, lifestyle and patient education cannot be overlooked, as weight loss remains a crucial factor in improvement of condition and reduction in risk of complications.

5. Preventing or delaying complications - Pharmacists can contribute to the appropriate management of complications, and the risk factors for complications. Optimal glycaemic control in both type 1 diabetes and type 2 diabetes reduces, in the long term, the risk of microvascular complications including retinopathy, development of proteinuria and neuropathy. Effective monitoring and understanding how to alter dietary and insulin requirements based on the results can have an impact on reducing diabetic complications. Many patients now monitor their own blood- glucose concentrations and since blood-glucose concentration varies substantially throughout the day, ‘normoglycaemia’ cannot always be achieved on a daily basis without causing damaging hypoglycaemia. Therefore, it is best to recommend that patients should maintain a blood-glucose concentration of between 4 and 9 mmol/litre for most of the time (4–7 mmol/litre

pre-prandial and less than 9 mmol/ litre post-prandial), while accepting that at various times, it will be above these values; however, the patient should be aware of the dangers of blood-glucose falling below 4mmol/litre, and make a strong effort to avoid this. Patients using multiple injection regimens should understand how to adjust their insulin dose according to their carbohydrate intake. With fixed-dose insulin regimens, the carbohydrate intake needs to be regulated, and should be distributed throughout the day to match the insulin regimen. A measure of the total glycosylated (or glycated) haemoglobin (HbA1) or a specific fraction (HbA1c) provides an indication of glycaemic control over the previous two- three months. The ideal aim for an HbA1c (glycosylated haemoglobin) concentration is between the range of 48–59 mmol/mol or less

(reference range 20–42 mmol/ mol) but this cannot always be achieved and for those using insulin there is a significantly increased risk of disabling hypoglycaemia. Approximately 70 per cent of people in Scotland with type 2 diabetes have an HbA1c of 58 mmol/mol or under. For people with type 1 diabetes, approximately 25 per cent have an HbA1c of 58 mmol/mol or under, whereas about 44 per cent have an HbA1c value of over 75 mmol/mol.

Therefore, it is obvious the impact that involving pharmacists and their pharmacy teams can have in a diabetic patient’s treatment journey, in maximising the potential of their therapy, and help those patients take ownership of their management and lead a high quality of life in spite of the condition, having knock-on effects for financial burdens also. •

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