Diabetes Patients and MURs

1. Diabetes Patients and MURs Chris Roome Interface Development Pharmacist, RD&E

2. Diabetes –a recap • Type 1 • Insulin dependent due to failure of insulin secretion • Typically younger patients • Accounts for around 10% of prevalent cases • Type 2 • Non insulin dependent (although some eventually require insulin). Primarily due to resistance to action of insulin • Typically older, overweight patients • Accounts for around 90% of prevalent cases

3. Diabetes definition • Diagnosed by abnormal plasma glucose measures: • Symptomatic plus fasting glucose >7 mmol/l random glucose >11.1 on one occasion. Or • No symptoms plus above measurements recorded on two occasions

4. But diabetes is not just about plasma glucose levels • When conducting an MUR on a diabetic patient think: • Blood sugar • Cardiovascular risk • Complications of diabetes

5. Management of hyperglycaemia-Insulin • Insulins- now many types and a multitude of devices giving rise to potential confusion. • Check the patient uses these appropriately • Check for recent changes in medication especially with switches to the newer analogues • Have there been any problems since the change eg hypos, and how have these been managed? • Check which health professional usually looks after the diabetes eg GP, practice nurse, local specialist centre as this may affect the communication necessary as a result of the MUR

6. Insulins – recap of types ‘Traditional ‘ Insulins • Short acting soluble insulin eg actrapid • Usually given 15 minutes before eating • May be used as part of a basal-bolus regimen given tds before the meals with use of an intermediate acting product at night time (or sometimes twice daily). Allows for flexibility of meals but must be used intelligently • May be used in twice daily regimens with intermediate acting insulins either as a pre mixed fixed ratio eg mixtard range or patient self mixed with isophane insulin eg insulatard

7. ‘traditional insulins cont’d • Intermediate acting eg insulatard • Onset of action 1-2 hours, peak 4-12 hrs, duration up to 24 hours. • Used in type 1 diabetes as part of the basal-bolus regimen or in self mix bd regimens. Used in type 2 diabetes (+OHDs) as a night time dose. • Long acting traditional insulins such as insulin zinc suspension are now rarely used

8. Newer insulin analogues • Very short acting (eg lispro, aspart, glulisine) • Very fast onset so may be given immediately before or straight after a meal. • Shorter duration of action that soluble insulin so possibly less problems with hypos. • Long acting analogues (glargine, detemir) • Onset 2-4 hours duration up to 24 hours, but some patients require bd dosing

9. Disposal of sharps • Check the patient knows how to and actually does dispose of the needles and syringes appropriately. (sharps containers and route of disposal)

10. Type 2 diabetes-usual management plan • First line management in type 2 diabetes is diet • If this fails all patients except the underweight will generally commence metformin • If HbA1c not sufficiently controlled add a sulphonylurea • If still not controlled consider glitazones or insulin

11. Metformin • Doesn’t stimulate insulin production so doesn’t cause hypos • Good evidence for reduced risk of diabetic complications (MI etc) • Commonly causes GI upset. Usual to start with low dose (500mg od) and increase slowly. Taken after food to minimise GI irritation If compliance is an issue due to GI upset check patient is taking after food. If recently started or dose increase the patient may be able to tolerate a lower dose with possible later increase which would be more beneficial than stopping. (might try 250mg alt die to start) • Check compliance with regimen (often tds and big tablets especially the 850mg!)

12. Sulphonylureas • Act by increasing insulin secretion • May produce hypoglycaemia (which can be severe and life threatening). Patients should carry a card/tag. Long acting agents are more likely to cause problems especially in the elderly. • Usually quite well tolerated but check patient is taking them as prescribed (many are BD dosing)

13. Glitazones • Act by reducing insulin resistance. • Mechanism of action means they may take up to 2-3 months to exert their effect. Might need to encourage a patient to continue if they want to cease therapy due to an apparent lack of benefit. • May cause weight gain • Potential serious s/e is development of heart failure- beware reports of new onset fluid retention, breathlessness etc.

14. Monitoring blood glucose • The PCT spends more on prescribed testing strips than on oral hypoglycaemic drugs. • The PCT has agreed a testing plan with the local consultants and patient groups. • The principal is only to test if the result will lead to a change in therapy/dose. Therefore the recommendations are different dependant upon use of insulin or not.

15. Blood Glucose testing for patients on insulin • If on a regimen where the dose of insulin is adjusted in relation to meals and lifestyle eg basal-bolus then testing up to 4 times a day may be indicated (pre meals and bed time). The patient will have been instructed how to adjust dose in response to the readings • If a type 2 diabetic on insulin testing once a day at different times of day including first thing in the morning will build up a profile which the healthcare professional can use to advise on dose adjustment.

16. Blood glucose testing for patients on oral hypoglycaemic drugs • Unnecessary if on metformin • If on sulphonylureas (or meglitinides) where there is a risk of hypos testing up to 3 times a week is recommended.

17. Other issues related to blood glucose • Patients at risk of hypoglycaemia should carry or have access to ‘medication’ for a hypo- a source of dextrose- could be tablets, medication (eg.hypostop) or food. • Patients relatives may need to administer glucagon. Need to check expiry dates if rarely used. Need to know what to do in an emergency.

18. Medication for cardiovascular risks of diabetes1.Hypertension • Control of blood pressure is essential to prevent long term complications. • NICE guidance is to treat in type 1 diabetes if BP>135/85 (or 130/80 if kidney damage) using thiazides as first line. Use ACEi if evidence of kidney damage, including microalbumiuria.

19. Management of BP • In type 2 diabetes NICE guidance is to treat if BP>160/80 but • Treat if BP>140/80 if history of CVD or >15% 10-year risk • Treat above patients with either ACEi or thiazide as first line • If >140/80 and with evidence of kidney damage treat with ACEi as first line and treat to target of 135/75 • Where an ACEi is indicated but not tolerated an AT2 antagonist may be used

20. MUR opportunities with antihypertensives • Diuretics Check compliance. Treatment choice is low dose bendroflumethiazide which should not cause troublesome diuresis when taken om. Higher doses offer little/no therapeutic benefit but will increase side effects. [also consider clinical issues of metabolic disturbance- low K, low Na, glucose]

21. ACE Inhibitors • Check compliance- These are not as well tolerated as might be expected see side effect list in the BNF • ACE cough- widely recognised but avoid making a ‘knee jerk’ diagnosis and recommending a switch. Most of the evidence of benefit of blocking renin angiotensin system is with these. Cough could be viral, asthma, CHF or other pathology. Look for temporal association and if possible organise a re challenge. • Check K intake (no salt substitutes etc)

22. Medication for cardiovascular risks of diabetes2. Lipids • In type 1 diabetes NICE recommend statins for those with kidney damage, >2 features of the metabolic syndrome, age>35, FH, high risk ethnic group and severe lipid abnormalities. • In type 2 diabetes NICE recommend statins if TC>5 with >15% 10-yr CVD risk (consider a statin at lower risks). • Fibrates may also be used if Triglycerides are raised

23. Statins • On theoretical grounds simvastatin should be taken at night (the cholesterol fairy!) but in practice take at a time the patient will reliably remember it. • Main serious side effects are liver (not obvious) and myopathy (pt may report muscle tenderness etc- should not be ignored-refer back to GP). Increased risk of myopathy when used in combination with a fibrate. • Other non serious side effects common and may limit compliance -check

24. Statins • Simvastatin and atorvastatin are metabolised via c p450 giving rise to a number of important interactions increasing toxicity • Avoid grapefruit juice • Avoid simvastatin with potent CYP3A4 inhibitors such as macrolides and azoles • Max dose 10mg with ciclosporin, gemfibrozil, niacin • Max dose 20mg with amiodarone and verapamil • Max dose 40mg with diltiazem • Atorvastatin interacts with same range and advice is to ‘use with caution’

25. Medication for cardiovascular risks of diabetes2. Antiplatelets • In type 1 diabetes NICE recommend aspirin 75mg for the same patient group as statins. • In type 2 diabetes NICE recommend antiplatelets for secondary prevention and also in those with a 10-year CHD risk >15% if BP is controlled <145 systolic

26. Aspirin • very important intervention in secondary prevention of CVD • Usual to use dispersible (historically cheaper) • No clinical advantage to EC preps -if patient finds dispersible unpalatable use the ordinary tabs • Concurrent use of aspirin with a COX-2 inhibitor removes the small reduced risk of GI complications. Need a PPI (probably with a traditional NSAID given adverse CV effects of COX 2 inhibitors) BUT both COX2 inhibitors and NSAIDS are best avoided in pts with renal disease unless no other alternative.

27. Medications for other complications of diabetes • Neuropathic pain • Amitriptyline- started low increased gradually • well known and troublesome adverse effects –check for compliance, knowledge of use and benefit • Gabapentin-gradually increasing titration schedule. Side effects of dizzyness may be common • Antiepileptics- carbamazepine, phenytoin, sodium valproate- check for knowledge of use and compliance with regimen. Also beware drug interactions with these!

28. Other complications of diabetes which may result in medication • Gastroparesis- prokinetics or erythromycin • Erectile dysfunction

29. Remember diabetes isn’t just about blood sugar control • When conducting an MUR on a diabetic patient think: • Blood sugar • Cardiovascular risk • Complications of diabetes