Meetings

Learning together in diabetes care

Irene Gummerson, a pharmacist with a special interest in diabetes, reports from a conference on new treatments and trends in diabetes care

The conference was organised by the Yorkshire Region of the Royal Pharmaceutical Society and the United Kingdom Clinical Pharmacists Association and held at the Holiday Inn, Brighouse, Yorkshire, on 10 October

Pharmacists can make a difference to the lives of people with diabetes and ease the increasing pressure that doctors and nurses are experiencing, according to Paul McLean, pharmacist at North Durham Hospital, who explained that he became involved in running a “Pharmacotherapy” clinic on the invitation of the consultant. “The prevalence and cost of diabetes is on the increase and studies show that patients make best progress if seen more often,” he said.

His training included many sessions sitting in with the consultant. When the clinic was about to start in 2002, the local diabetes facilitator helped him by writing to local GPs, informing them about the imminent clinic. Referrals (from the consultant and now also from diabetes specialist nurses) are for people with type 2 diabetes on oral medication and with complications, eg, hypertension, dyslipidaemia.

Mr McLean said that the aim was to stem the rise of micro- and macro-vascular diabetic complications by improving control of blood glucose, blood pressure and lipids. It is difficult to reach a glycaemic (HbA1c) target of 7 per cent in a patient diagnosed for over seven years, he said. Tight control of BP protects renal function and prevents micro- and macro-vascular disease, but again, it is not easy to reach a target of 130/80mmHg or lower, and many patients are on two, three or four antihypertensive drugs.

Mr McLean reviews patients’ medication, gives lifestyle advice and routinely checks HbA1c, BP, fasting lipids, urea and electrolytes, and liver function tests. He emphasised that the risk of non-adherence can be reduced by clarifying the reasons for prescribed medicines. Mr McLean communicates results and treatment recommendations to GPs by letter. Ninety-one per cent of his recommendations are acted on, however since he has just finished his supplementary prescribing course, soon this will be less of a problem, he said.

New drugs for type 2 diabetes

“Pharmacists have a powerful role in encouraging people to change behaviour,” said Richard Pope, consultant at Airedale General Hospital. He advised pharmacists to find novel ways to engage people in their health care.

Lifestyle interventions reduce the risk of progressing to the metabolic syndrome by 58 per cent. The level of change required is a 10lb weight reduction and 150 minutes of exercise per week, said Dr Pope. He advised that metformin was the first choice in overweight patients with type 2 diabetes. “Evidence shows it can reduce disease progression by 30 per cent. If patients are not tolerating metformin, check whether they as taking it after food,” he advised.

“Glitazones [roziglitazone, pioglitazone] improve sensitivity to insulin and are now licensed as monotherapy, if there is intolerance to metformin,” said Dr Pope. He told delegates that triple therapy [metformin, sulphonylurea, glitazone] was not sanctioned by the National Institute for Clinical Excellence, except in special circumstances. “Anecdotally, consultants are trialling triple therapy. If a patient is on metformin and a sulphonylurea, and the consultant wishes to change the latter to a glitazone, they leave the patient on the combination for two to three months and include a glitazone. Otherwise when the sulphonylurea is removed and replaced by a glitazone, the blood glucose rises since the latter takes two to three months to work,” he explained.
Long-acting insulin analogues, eg, glargine (Lantus), are useful in difficult cases of type 2 diabetes, producing less weight gain and hypoglycaemic attacks. He finds that high glucose levels are harder to control, and often reduces these with insulin in people with type 2 diabetes and then weans them off it.

Trials are under way with Exubera (oral/ inhaled insulin). Another exiting area is research into rimonabant (cannabinoid receptor antagonist) a novel approach to tackling smoking and obesity. Early studies show weight loss, a decrease in nicotine dependence and an increase in insulin sensitivity.

Screening services

Julian Hickman, professional development manager, Lloydspharmacy, gave an update on the Lloydspharmacy service — screening for hypertension and diabetes in community pharmacies. “When setting up a service consider workforce planning, structural requirements, SOPs and guidelines.” Pilot sites found they were testing the 40 to 70 age range, with an 18 per cent referral rate, and that male, black and Asian customers were more likely to be referred. Customers were given results and advice, however a follow-up showed that not all referred customers visited their GP practice.

Conflicting guidelines for diabetes care in UK

“Evidence is helping to raise standards and lower the bar [target levels],” believes Peter Hammond, consultant physician and endocrinologist, Harrogate District Hospital. However, the increasing number of evidence-based guidelines do not always advise the same course of action, eg, NICE guidelines versus British Hypertension Society guidelines. There is also a lack of clarity in respect of the implementation of these guidelines and ensuring adherence, he added.

Ways in which adherence to treatment can be achieved, he suggested, include simplifying dosing, eg, combination drugs, educational interventions where the treatment is explained to the patient, telephone and computer-assisted monitoring, interventions prompted by family, provision of care at the workplace, eg, occupational health nurse, and a health care team approach.

PCT clinic experience

Karen Goodyear, a community pharmacist in Hull, has found that group education sessions with diabetes specialist nurses and dietitians are time-efficient. Blood tests and blood pressure readings are taken by the practice nurse. The pharmacist then has a one-to-one follow-up appointment with the patient, having seen the test results in advance, and has the opportunity to evaluate the group education session. The pharmacist writes a clinical management plan for discharge back to GP care. A dietitian and a podiatrist are available once or twice a month. Mrs Goodyear has also found a useful ally in the local diabetes facilitator, who is addressing the problem of some GP practices needing constant prompting to implement changes in medication. She also finds the “Diabetes E” internet-based system useful to access how many people are reaching target levels. “In my experience diabetes specialist nurses are confident with diabetes care, but are nervous about other drugs. They value medication reviews done by a pharmacist,” said Mrs Goodyear.