Diabetes care
New developments in diabetes care
Use of inhaled insulin will be limited in practice, said Dinesh Nagi,
consultant in diabetes at Pinderfields Hospital, as he discussed new
developments in treatments for diabetes. He said that use of the recently
licensed Exubera (inhaled insulin) may be limited since patients will
require lung function tests — and these may be difficult to organise
in already busy respiratory departments.
Dr Nagi also raised the concern that inhaled insulin may lead to an increased
production of insulin antibodies. In his opinion it will only be an option
for patients with “true needle phobia”.
Dr Nagi described exanitide as an exciting development. This is a new
therapy which suppresses glucagon secretion and glucose production in
the liver. It signals to the brain when the stomach is full which will
help people with type 2 diabetes lose weight, Dr Nagi said. He commented
that patients lose an average of 10kg over two years on this treatment,
although there are problems with patient tolerability because it is associated
with a high incidence of side effects.
The recently licensed rimonabant is an interesting compound since it
blocks the endocannabinoid system — the system involved with feeding
behaviour, hepatic lipogenesis and glucose homoeostasis. It has been
shown to promote an average weight loss of 6kg, increase high density
lipoprotein cholesterol by 10–12 per cent, reduce triglycerides
by 5–10 per cent and lower plasma glucose and HbA1c. Dr Nagi said
that rimonabant would be useful for people with type 2 diabetes and for
those patients with metabolic syndrome. It is still not known whether
this drug will prevent cardiovascular disease and diabetes mellitus if
used by people with metabolic syndrome. There are, as yet, no long-term
studies to answer this question, Dr Nagi said.
Better drug practice in diabetes
It is stated that 93 per cent of people with type 2 diabetes mellitus
have a predominant abnormality of insulin resistance. However, Peter
Hammond, consultant physician and endocrinologist at Harrogate Hospital,
believes it is actually 100 per cent of people with type 2 diabetes.
Therefore he believes that the most effective prevention strategy
is an aggressive approach to lifestyle intervention in people before
they develop diabetes.
Dr Hammond also suggested that thiazolidinediones (eg, pioglitazone)
should be
perhaps considered for use earlier in a patients’ treatment rather
than left as the last agent to be added in a triple therapy drug regimen.
He said that, in his practice in secondary care, he finds insulin, metformin
and a glitazone a good combination, although it is still contra-indicated
in the UK (used in the US).
Dr Hammond also said that, in his opinion, sulphonylureas should be regarded
as third-line agents and added once a patient is established on metformin
and a glitazone.
Dr Hammond commented that practitioners are too conservative with dose
titration of oral anti-hyperglycaemics and really should increase the
dose at two-weekly intervals according to home blood glucose monitoring
results.
“Angiotensin receptor blocking drugs are not superior to angiotensin
converting enzyme inhibitors and I consider ACEI as first-line,” Dr
Hammond stated. He also mentioned the limited evidence on the combined
use of
ARBs and ACEIs in the CALM study (lisinopril and candesartan in patients
with established microalbuminuria). He described that dual blockade with
an ACEI and ARB was an attractive approach in patients with nephropathy
and he has some successful experience of using this combination.
On discussing the use of statins in people with diabetes, Dr Hammond
stated that, in his opinion, all people over the age of 40 years with
diabetes should be offered a statin irrespective of their initial lower
density lipoprotein cholesterol reading. He believes that there are beneficial
effects in risk reduction for patients irrespective of their starting
cholesterol. However he did recognise that this does not necessarily
apply to children or the elderly, the lower risk ethnic groups and patients
with renal failure.
Think more about services that can be provided through PBC
Community and hospital pharmacists will need to think more broadly about
what services they could provide in the practice-based commissioning
era, Duncan Petty, research pharmacist at Leeds University, said. “If
we don’t then we may lose out.” There is a huge drive for
private providers to bid for and provide services.
The pharmacy profession could bid to deliver new services but it would
need to make a strong case which fits in with commissioning intentions
and their priorities, and shows clear value for money, Dr Petty said.
He also emphasised the point that pharmacists must work with doctors
and not against them in this process.
Dr Petty stated that that it was likely that outpatient services would
be shifted from hospitals to GP practices and primary care centres. Diabetes
would be a prime example of a service that could be delivered in the
community. He said that it was possible that hospital pharmacists or
pharmacists with a special interest in diabetes could be commissioned
by PBC to manage patients with
diabetes. |
The
Pharmaceutical Journal