DIABETES
> This was of considerable 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 recognised, and there are various ways in which they can do this. for a start, focusing on five checkpoints in the patient’s journey 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.
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. 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. Some common symptoms of undiagnosed diabetes include: • Increased thirst • Increased frequency of urination, especially at night, and cystitis
• lethargy • Weight loss • genital itching or regular episodes of thrush
• Blurred vision
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) that is available in northern Ireland, and which provides initial assessment and review of Type 1 and Type 2 diabetic patients who are prescribed various forms of anti-diabetic medication.
16 - PhArMACy In foCUS
Therefore, it is best to recommend that patients should maintain a blood-glucose concentration of between four and nine 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. The patient should, however, be aware of the dangers of blood-glucose falling below 4mmol/litre, and make a strong effort to avoid this.
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 it is managed; its complications and how they can be prevented; and how diabetes can impact on life in issues such as 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.
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 2–3 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.
Despite many advancements in diabetic care surrounding available treatment and patient education, northern Ireland is still spending around £1 million treating diabetes. There are more than 22,000 people on the diabetes register under the northern health and Social Care Trust, and it is estimated that 235 people in the region lost limbs in 2015 as a result of the condition. The potential severity of diabetes can therefore never be overlooked.
A pilot foot care programme known as ‘The Diabetes foot Pathway’ scheme at the Causeway hospital has now been implemented and this
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is already pushing down amputations due to diabetes-related illness by 90 per cent. The scheme provides patients with the chance to see a podiatrist, dietician and nurse in the same clinic within a 24-48-hour time frame.
Additional powers are granted to gPs to refer emergency cases which ensures that that patient is seen by a qualified professional within the same day. Elaine Davidson, the principal podiatrist for the trust, has stated that ‘you can get blockages in the arteries, so a minor trauma to the foot can cause blisters, which can sometimes mean a foot emergency. We need to treat those patients within 24 to 48 hours.’ furthermore, gP Brian Connor, who is leading the project, said: ‘for many people who have diabetes this can be the silent killer. In the northern health Trust, we have so many patients; the highest number of patients across all of the health Trusts, who have had amputations due to diabetes. not only is this having an impact on the patients' lives, but also on the health service due to the costs incurred. In fact, northern Ireland spends around £1 million a day treating diabetes.’
It is necessary therefore that pharmacists and their pharmacy teams involve themselves in a diabetic patient’s treatment journey in order to maximise 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.
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