Diabetes care in the pharmacy Print E-mail
Written by Dinesh Jivanji   
Diabetes mellitus describes a complex, heterogenous group of metabolic disorders that is a major source of ill health. Recent figures from the Quality and Outcomes Framework reveal that the UK now has more than 2 million people with diabetes, representing over 3 per cent of the population. Of these, about 250,000 have type 1 diabetes and over 1.8 million have type 2. The impact of diabetes on the health of individuals and populations, and the rising cost of providing and improving healthcare for diabetics, has thrust this condition at the forefront of public and community health intervention in the UK. Although there is abundant knowledge about interventions that can substantially reduce both morbidity and mortality, and improve quality of life, the translation of this knowledge into clinical/public health practice remains substandard.

Government recognition of pharmacists’ skills and the birth of the new contractual framework for pharmacy mean that community pharmacists are now expected to play a substantive role in improving outcomes in patients with long-term conditions including diabetes.

This article briefly explores the main components of diabetes care where community pharmacists can make a significant contribution in terms of better management of the condition and alleviating the economic burden of acute and long-term complications.

Glycaemic control


It is well known that control of hyperglycaemia can significantly reduce microvascular complications of diabetes1,2,3. Self-monitoring of blood glucose (SMBG) and glycosylated haemoglobin (HbA1c) measurements play a central role in optimising blood glucose levels in patients. To ensure that SMBG and HbA1c tests confer maximum benefits in terms of glycaemic control, it is imperative that:

  • Patients are well informed about the value of these tests and have clear awareness of the targets set for them;
  • Pharmacists help in evaluating patients’ SBGM technique and their ability to interpret results and adjust therapy.

Nutrition


Appropriate nutritional advice and information is essential for the effective management of diabetes2. Goals of
dietary advice are:

  • To improve health through use of healthy food choices;
  • To facilitate and maintain optimal metabolic and physiological outcomes including:
    • – Achieving near-normal glycaemia, thereby reducing the risk of microvascular complications;
    • – Reducing the risk of macrovascular complications by managing body weight, hypertension and dyslipidaemia.

Although registered dietitians play a pivotal role in implementing nutrition therapy, it is essential that pharmacists are knowledgeable about nutrition and are supportive of people who need to make lifestyle changes.

Weight management and exercise


Obesity is an independent risk factor for hypertension and dyslipidaemia as well as cardiovascular disease1,2. Moderate weight loss reduces cardiovascular disease (CVD) risk, improves glycaemic control and blood lipids profile. In most cases, the primary approach for achieving weight loss requires therapeutic lifestyle change, which entails a reduction in calorie intake and an increase in physical activity. In selected patients, drug therapy (e.g. orlistat or sibutramine) may be necessary to achieve weight loss. The new pharmacy contract provides a great opportunity for community pharmacists to set up weight management clinics that can assess patients’ body mass index (BMI) and provide comprehensive advice on nutrition and exercise for the overweight and obese.

Preventing vascular complications 1,2,4,5 CVD


CVD is the greatest overall cause of morbidity and mortality in diabetes. In Type 1 diabetes, the major risk is microvascular complications, although macrovascular complications are also increased. Type 2 diabetes is usually accompanied by metabolic syndrome, which is associated with other CVD risk factors such as central obesity, hypertension and dyslipidaemia. Reducing these risk factors can prevent or slow down CVD. It is thus important that steps are taken to minimise all CVD risk factors, some of which are discussed below.

Hypertension
Generally, people with diabetes should aim for blood pressure lower than 140/80 mmHg (ideally under 130/80mm Hg). Pharmacists can help patients reach this target by advising on lifestyle modifications, including losing weight, increasing physical activity, moderating alcohol consumption, and smoking cessation.

Furthermore, pharmacists can help patients achieve their blood pressure targets by checking their blood pressure routinely. This can be done on a monthly basis when patients visit the pharmacy to collect their repeat prescriptions. Where blood pressure remains sub-optimal, pharmacists can liaise with the patients’ doctors to recommend pharmacotherapy (if dietary/lifestyle modification is insufficient) or change in pharmacotherapy (e.g. maximising the antihypertensive dose or adding an antihypertensive) in order to achieve the blood pressure target.

Dyslipidaemia
People with diabetes should be informed that lifestyle modification strategies focusing on reduction of saturated fat and cholesterol intake, weight loss, smoking cessation and increased physical activity result in improved lipid profile. Pharmacological treatment is indicated if lifestyle modifications do not result in targeted lipid levels. As well as ensuring that patients comply with their cholesterol medication, pharmacists can offer cholesterol-monitoring facilities to help patients track their lipid levels.

Antiplatelet agent
Aspirin therapy, usually 75mg/day, is recommended as a secondary prevention strategy in all diabetics with a history of CVD. For primary prevention, aspirin is considered in patients who are deemed to be at increased CVD risk because of, for example, their family history, smoking, hypertension, dyslipidaemia or albuminuria. By carrying out pharmacy-based audits, pharmacists can identify those people with diabetes who are not on anti-platelets and assess their eligibility for such therapy based on information acquired from them and their medication records.

Smoking cessation
Studies of diabetes patients have consistently shown a heightened risk of morbidity and mortality associated with development of macrovascular complications among smokers. Furthermore, smoking strongly correlates with premature development of microvascular complications of diabetes. Community pharmacists can help smokers to quit by setting up PCT-funded smoking cessation services as a routine component of diabetes care.

Microvascular complications
The most important contributing factor towards microvascular disease is the toxic effect of chronic hyperglycaemia, with hypertension being a significant exacerbating factor. Controlling hyperglycaemia and hypertension can significantly reduce microvascular complications (nephropathy, retinopathy and neuropathy) in both type 1 and type 2 diabetes. It is crucial that patients are educated on the signs/symptoms, as their early recognition and prompt referral for a check-up can profoundly affect prognosis. Community pharmacists are well placed to inquire from their patients if they are being screened regularly for microvascular complications in order to ensure early detection and management.

Other complications 1,2


Acute illness
During periods of sickness, people with diabetes often need to be reminded to continue taking their insulin or oral hypoglycaemics. Although calorific consumption may decrease, insulin sensitivity is reduced. Frequent monitoring of blood glucose can prevent both hypoglycemia and hyperglycaemia.

Acute glycaemic complications

  • Hypoglycaemia – Any person with diabetes who takes an oral hypoglycaemic or insulin may experience hypoglycaemia. The likelihood of severe hypoglycaemia increases in patients who are on intensive insulin regimens, whose diet and activity vary widely, and/or who have autonomic neuropathy.
  • Diabetic ketoacidosis (DKA) – This is a rare but serious condition characterised by hyperglycaemia, acidosis and ketonuria. It usually presents in type 1 diabetes and is a consequence of severe insulin deficiency.

Patient education is crucial in preventing acute complications. In particular, patients must be taught how to care for themselves when they are ill, how to monitor themselves, and what to do when faced with an acute gylcaemic episode.

Infections
People with diabetes are at increased risk of infections including gum disease (periodontitis), skin infections, influenza, pneumonia, bladder and kidney infections, vaginal yeast infections, and foot infections that may lead to foot or leg amputation. Hyperglycaemia resulting from uncontrolled diabetes plays a pivotal role in susceptibility to infections. Pharmacists should be alert to diabetes patients who frequently request over-the-counter remedies for conditions like vaginal thrush, gum disease and bladder/kidney infections, as these people are likely to have poor glycaemic control. They should be encouraged to have pneumococcal and/or influenza vaccinations if eligible.

Conclusion


Community pharmacists can play a crucial role in diabetes management, especially in the context of new opportunities afforded by the new pharmacy and General Medical Services contracts. Pharmacists can increase their involvement in diabetes management via a number of routes, which include:

  • Optimising on the opportunities embedded in the three levels of the new pharmacy contract:
    • – Essential services: e.g. public health advice, sign posting and self-care;
    • – Enhanced services: e.g. carrying out full clinical medication reviews and setting up clinics for blood glucose monitoring (including HbA1c), cholesterol testing and blood pressure monitoring;
    • – Advanced services: e.g. medication use reviews and prescription interventions;
  • Becoming a supplementary prescriber specialising in diabetes;
  • Engaging in practice-based commissioning related to diabetes care.

References
1. Cantrill JA, Wood J. Diabetes Mellitus. In Walker R, Edwards C (eds). Clinical Pharmacy and Therapeutics 3rd Ed. Edinburgh: Churchill Livingstone, 2003: 657–677.
2. American Diabetes Association: Standards of Medical Care in Diabetes – 2006. Diabetes Care 2006; 29: S4-S42.
3. NICE. Management of type 2 diabetes: Management of blood glucose. Inherited Clinical Guideline G; September 2002.
4. NICE. Management of type 2 diabetes: Management of blood pressure and blood lipids. Inherited Clinical Guideline H; October 2002.
5. NICE. Type 1 diabetes: diagnosis and management of type 1 diabetes in adults (quick reference guide). Clinical Guideline 15; July 2004.
 
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