diabetes, a continuing programme of education from diagnosis, support and access to psychological services should be provided.

Again, it’s important to ensure that the programme includes the following core topics:

• HbA1c monitoring and targets

• the effects of diet, physical activity, body weight and intercurrent illness on blood glucose control

• the aims of metformin therapy and possible adverse effects

• the complications of type 2 diabetes and how to prevent them

Any conversations with the child/ young person and their family should be approached with care and in a sensitive manner, taking into account the difficulty some may have with weight reduction and potential stigma around being overweight.

Standard release Metformin should be offered concurrently with lifestyle changes.

The optimal targets for short-term glycaemic control (that is, for glucose self-monitoring) are:

• For children and young people, a pre-prandial (before eating) blood glucose level of 4.0–8.0 mmol/L and a post-prandial (1 hour after eating) blood glucose level less than 10.0 mmol/L.

ADHERENCE ISSUES The issue of adherence in children and young people can be a complex and challenging one.

Factors that appear to have a positive impact on adherence are4


• positive family functioning, • close friends,

• an understanding of the importance of control,

• treatment with immediate benefits,

• parent’s beliefs in seriousness of illness and efficacy of treatment,

• physician empathy

Other factors that seem to have a negative impact on adherence are being an older adolescent, mental health issues with the caregiver, family conflicts, complex therapy, medication with side effects and denial of illness.

Teens that are experiencing emotional, social, family or mental health problems struggle more with adherence and a disinterest (or dismissiveness) in the treatment plan can be a sign of depression or other psychosocial problems4


Another factor to adherence is the maturity level of the child or young person. Adolescence is an important stage in growing up and changes in their physical and mental states can greatly impact their treatment.

Possibly of much more importance to them are the psychosocial changes, including identity formation and the development of independent social relationships.

Many young people don’t want to be different and there is a great potential for them to see themselves as ‘not normal’. It is important to ‘fit in’ with their peers and having to stick to a treatment plan that involves injecting medication and dietary requirements can make them feel like they stand out. Also, the child will move from complete dependence to a more independent lifestyle where they are expected to take increasing responsibility for their health and health care.

Ways to improve adherence would be to take into consideration all of the above issues and to work with the patient to help support them through this transition. Good transition programmes improve outcomes and there is emerging evidence that well organised transition protocols and programmes do have measurable benefits for young people and their parents. This is in relation to changes in morbidity and mortality. Benefits include improved follow-up, better disease control and improved documentation of transitional issues5


It is important to tailor the education programme to each child or young person with type 1 diabetes and

their family members or carers. Many young people complain of being spoken down to or spoken to like a child. This will depend on the maturity level of the child/young person but involving them in any decision making will encourage them to stick to any treatment plans that are developed. This will involve taking account of personal preferences, their existing knowledge of the condition, any current or future social circumstances and finally their life goals3


As pharmacists, we can provide the support they may need. We can act as an impartial party if they want to seek advice on any personal issues or struggles they may be having but also to answer any questions regarding their treatment regimes. Sometimes all that is needed is someone to talk to.


1. targets, NICE Guidlines sticter glucose. article/stricter-blood-glucose-targets- for-people-with-diabetes. [Online] 2. England, Public Health. https:// obesity_and_health/health_risk_child. [Online]

3. NG18, NICE Guidance. https://www. ftn.footnote_1. [Online] 4. Issues, Adherence. https://www.ncbi.nlm.nih. gov/pmc/articles/PMC2528818/. [Online] 5. People, Transition Getting it Right for Young. http:// uk/20130107105354/http://www. dh_digitalassets/@dh/@en/documents/ digitalasset/dh_4132149.pdf. [Online]

Diabetes: the role of the pharmacist

by Kurtis Moffatt

Despite the many advancements in diabetic care surrounding available treatments and patient education, diabetes is still an urgent health issue, as Scotland is spending ten per cent of the annual NHS budget on treating the condition, which is the equivalent of £100,000 hourly. The number of Scots living with diabetes has risen each year by 25 per cent since 2008. Over 276,000 people in Scotland now have diabetes and every day 48 new patients learning that they have the condition. Additionally, based on current trends it may indicate that, by

2035, more than 480,000 people in Scotland will be living with diabetes.

Diabetes not only has a large impact on the annual expenditure for NHS Scotland, but also has significant personal costs for sufferers of the condition, which is estimated currently at £50 million a year. These costs are incurred due to patients missing work, travel costs for medical treatment and loss of employment or early retirement because of ill health, as it has been found that about six per cent of people with type 2 diabetes are unable to work at all. The total cost (both direct and indirect) associated with diabetes in Scotland is currently predicted around £2.37 billion. These costs are estimated to rise to £3.98 billion by 2035–36.

Pharmacists play a key role on the frontline support of diabetic patients, and can have an impact on patient’s

quality of life and also driving down financial burdens, being the most appropriately qualified to advise patients on how to use medication to manage their condition. Additional support may be provided in the form of lifestyle recommendations and dietary interventions. However, despite the pharmacist being a valuable, easily accessible resource for this provision, a lack of public awareness means that patients and their carers are not taking full advantage of the services offered by their community pharmacist. This is unfortunate as it has been shown that involvement of the pharmacist within diabetes management significantly improves adherence to treatment regimens; which is particularly important in Type 2 patients, as patient adherence currently only stands at approximately 60 per cent to their prescribed treatment. Given the poor adherence rates associated with

Type 2, getting the right treatment and support to manage the condition is of utmost importance, as if blood glucose levels are not managed effectively (as with type 1) it may lead to tissue damage, which can also result in blindness, kidney failure, and foot ulcers which may ultimately end in amputation. Insulin may be incorporated with type 2 patients’ therapy who are poorly controlled by oral anti-diabetic medication alone, however it is seen as an end of the line option and presents a lot of drawbacks such as a potential patient fear of injectables, monitoring requirements and additional expenditure for the NHS. However, in 2016 NICE recommended three new treatment options for treatment of type 2 diabetes. The drug class known as sodium glucose co-transporter 2 inhibitors (SGLT2), exert their action by reversibly inhibiting sodium glucose >


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