DIABETES
the concern that the hypo may not be halted quickly enough and lead to embarrassment or even risk and danger is constant worry. furthermore, sugars often spike up after a hypo, leading to unpleasant ‘yo-yoing’ of sugars. .
‘It goes without saying, therefore, that the most positive outcome in the treatment of hypos is to avoid them in the first place, and one important element in this regard is education of the person living with diabetes. that’s where the pharmacist can play a vital role.’
Main causes of hypoglycaemia ‘In order to reduce the likelihood of hypos occurring, it is necessary for the person living with diabetes to understand the most likely causes of them.
‘In the case of ninsulin treatment, the most frequent cause of a hypo is a mismatch between insulin and carbohydrate intake. If, for example, the amount of insulin required at a mealtime is miscalculated, then hypoglycaemia may result. It is therefore important that people living with type 1 diabetes are educated with regard to understanding and calculating the carbohydrate content of food and the insulin they require to metabolise it.
‘another major cause of hypos is exercise. While exercise is clearly positive, in diabetes, exercise –
aerobic exercise in particular – can result in muscles using glucose as a fuel. this leads to a subsequent drop in blood glucose levels and can result in a hypo.’
New strategies that are being adopted Insulin pump therapy may be useful to reduce the number of hypos experienced by a patient and is being used increasingly in children, young people and others with type 1 diabetes. also, continuous glucose monitoring systems (cgmS) are becoming more available. these monitor blood sugar levels continuously, with the latest models able to feed back either to the patient
immediately should their glucose level be falling towards a hypo, or indeed feed that information to their insulin pump directly. the freestyle Libre has recently been approved for reimbursement in people living with type 1 diabetes.
this is known as a flash glucose monitoring system and checks interstitial glucose levels every minute via a device attached to the upper arm. the person living with diabetes (or a relative) can then swipe a monitor across the Libre device and the glucose level is displayed.
of additional benefit, a small graph displaying the glucose patterns over
the preceding eight hours are also shown and furthermore an arrow points upwards or downwards predicting how the sugar might change over the next short period of time.
these latter features are of benefit in aiding decisions about sugar levels and hence anticipating impending hypoglycaemia. a further option for some patients is that of transplantation.
an islet transplantation programme has now been set up in the UK and is a possibility for selected patients, with reduction in hypoglycaemia one of its benefits.
How the community pharmacist can help in hypo management
I never cease to be amazed how, according to surveys on diabetes, many people have little or no understanding of hypos.
In one recent study, for example, the participants stated that they believed their hypos were simply part of their condition and not related in any way to their medication. I believe that, as a primary care provider, the pharmacist has a major role to play in both recognising those who are at particular risk of severe hypoglycaemia occurring and also those who may be most affected by the effects of a hypo.
this may include, for example, those, who are developing renal impairment, as they may be
particularly susceptible to hypoglycaemia due to the prolonged effect of sulphonylureas or insulin.
these patients may be particularly assisted by having their egfr monitored several times a year to pick up on falling levels. Since the elderly are particularly at risk in this category, it could be a good idea to review their list of medications and to take appropriate action.
By helping a patient to understand their condition better, and by increasing their knowledge of both the causes and symptoms of hypos, you may help to not only reduce the incidence of hypos, but can help the person living with the diabetes to manage them better.
It therefore goes without saying that education is the first strategy which will help to reduce both hypos and the effect that they have on patients with diabetes. aim to educate your patients – particularly those, who are treated with insulin or sulphonylureas – on symptoms to watch out for in the lead-up to a hypo and on the steps that they should take immediately.
Knowledge of the factors that trigger hypos can not only help to reduce the risk of them occurring, but can reduce their effect. In addition to the person living with the diabetes, it is also vitally important that their relatives and carers are also educated as, very often, it is they who will have to deal with the effects of a hypo.
Education of the young person living with diabetes is particularly important in light of their social life. Information on the effects of alcohol, for example, may be very useful in reducing the risk of a hypo occurring on a night out, and you could suggest that the patient adopt the ‘buddy system’, whereby a friend quickly recognises the signs of a hypo and can take immediate action.
Education is another area in which the patient needs information and support. By understanding the effects of different types of exercise on blood sugars, the person living with diabetes can learn to adjust their carbohydrate and insulin intake to avoid hypos occurring.
PharmacY In focUS - 35
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