Features

Patients with diabetes: problems revealed by medicines use reviews

Patients with type 2 diabetes who do not respond satisfactorily to diet and exercise after three months are prescribed oral antidiabetic drugs. A medicines use review is an ideal way to help these patients take their medicines correctly.

The dosing of most sulphonylureas is linked with breakfast or the first main meal of the day so I ask patients to tell me when they take their tablets and if they ever miss any.

I also ask about their eating patterns. Patients prescribed metformin tds, the drug of first choice for those who are overweight, should take tablets during or after meals, corresponding to breakfast, lunch and dinner. Patients sometimes miss tablets with tds regimens especially if they go out for lunch or dinner.

I had one patient who had been prescribed a month’s worth of metformin and did not order a repeat prescription because he thought that he only needed to take it for a month, like a course of antibiotics. An MUR also flagged up an elderly patient being prescribed glibenclamide. This presents a greater risk of hypoglycaemia so I highlighted this patient to the GP and suggested considering a shorter-acting alternative, such as gliclazide.

An MUR involves asking about side effects. For gastrointestinal disturbances with metformin, I recommend taking the tablet after food. Patients taking sulphonylureas can gain weight. If a patient has put on weight, a review at the GP practice is advisable. For some, weight gain (also a side effect of rosiglitazone) can lead to non-compliance. On one occasion, I found a patient attributing numbness in his fingers to side effects rather than linking this to diabetic neuropathy and a need to see his GP or diabetes nurse.

Insulin

In general, I have found that patients with type 1 diabetes know more about the disease than those with type 2 diabetes. For patients prescribed insulin, I find out how they use it (eg, changing injection sites). I look at basics, such as if they have any difficulties using their device and if they know how to make adjustments to diet or insulin dosage according to blood glucose readings as well as in illness, trauma or stress.

One patient had readings over 10mmol/L in the mornings, and I found she was injecting her long-acting insulin with a short-acting one each morning. I referred her to her GP practice. I advise patients with uncontrolled diabetes to record readings in a “diabetes diary” to discuss with their GP.

For patients prescribed glucagon for hypoglycaemia, I might put “check the expiry date” as an action point on the MUR form. I have noticed that many patients dependent on insulin have not heard of sharps bins.

Although lancets and test strips are not medicines, checking the patient’s use of these is appropriate in an MUR. Some patients who are not on insulin believe they have to check their blood glucose every day when a once or twice weekly check should be sufficient (and would save on prescribing costs). On the other hand, I have come across patients using the same lancet for weeks, increasing their risk of infection.

For patients who use a blood glucose meter, it is worth checking that they calibrate it. Some patients do not know about control solution or where to get it so I note the telephone number for the manufacturer on their copy of the MUR form. (If a patient’s meter is old, some companies also provide a new one free of charge.) Many patients who do not use insulin would like to learn how to interpret their blood glucose levels and some report that readings are an incentive to live a healthier lifestyle.

An MUR is also an opportunity to talk about over-the-counter products and their sugar content. I have found that some patients do not look at the sugar content of medicines or do not know that sugar-free versions are available.

I usually record any advice I have given on the MUR form, even though there is no designated section. My employer provides patient information leaflets about cholesterol, blood pressure, smoking cessation and weight management, but a wider range of free leaflets is available to pharmacists in Norfolk from www.heron.nhs.uk

A general question I ask patients is whether they have a regular diabetes check-up. I also ask about physical activity and smoking status and note possible actions for the patient on the action plan page. Diabetes is a strong risk factor for cardiovascular disease so I also check if the patient has had a CVD risk assessment. Other risk factors may necessitate the prescribing of aspirin, statins or angiotensin-converting enzyme inhibitors.

Diabetes is a complex condition. I completed a Centre for Pharmacy Postgraduate Education learning pack on the condition about three years ago and trained to measure blood glucose when I worked for Lloydspharmacy (as part of a campaign to offer free diabetes checks to every customer). However, I revised my background knowledge before starting MURs and am still learning as I go along.

Knowing how to measure blood glucose helps me talk to patients. I recommend pharmacists learn how to do so from a representative from a blood glucose machine manufacturer, a diabetes nurse or a friendly patient. On a few occasions, I have measured blood pressure during an MUR but this and measuring blood glucose are far above service requirements.

A good knowledge of the possible complications of diabetes is needed. For example, pharmacists might be asked about preventing diabetic acidosis. During one MUR, I discovered the patient had been taking co-codamol for “nerve pain” for months when tricyclic antidepressants are first choice for painful diabetic neuropathy.

Conclusion

Performing MURs has allowed me to identify problems that would have otherwise gone unnoticed. I am pleased to have the extra opportunity to ensure patients have the correct information and understanding about their medicines. I have found it helpful when colleagues have shared their experiences. I hope this article will help pharmacists with their service provision.