Pharmacist ’ s role

1. Pharmacist’s role in Diabetes Mellitus

2. Pharmacist’s role • The pharmacist’s role in the primary prevention of diabetes • The pharmacist’s role in detecting undiagnosed diabetes • The pharmacist’s role in the prevention of complications • Referral criteria Quality standards • Questionnaire for People with Diabetes • Summary of revised WHO Diagnostic Criteria for Diabetes

3. The pharmacist’s role in the primary prevention of diabetes • Opportunistically promote a healthy lifestyle • Factors such as obesity and lack of physical activity have been strongly linked with the incidence of Type 2 diabetes and the rising world prevalence of Type 2 diabetes is mainly attributed to lifestyle changes. The modern diet of fast foods and high calorie drinks is not helpful. The prevention of obesity in children and young adults is particularly important. In addition, cardiovascular disease is a major cause of premature death in people with diabetes. Try to maximize your use of information material. You can obtain leaflets and posters from your local health promotion unit, pharmaceutical companies, Diabetes UK and other sources, e.g. the British Heart Foundation. Promotion of a healthy lifestyle is of course important at all stages of the disease process, whether it be primary prevention of diabetes or secondary prevention of complications. The importance of regular eye examinations should also be promoted.

4. Those who may be at risk include:* Over 40 years of age* Relatives of people with Type 2 diabetes * People with hypertension * People with hyperlipidaemia * People with history of myocardial infarction * Women who have had gestational diabetes * Obese or non-active and people of SE Asian/African Caribbean origin The symptoms :*Thirst and a dry mouth*Passing large amounts of urine. *Incontinence *Tiredness*Weight loss*Genital itching & blurred vision. If you suspect that a patient may have undiagnosed diabetes you should refer them to their GP. N.B. Revised diagnostic criteria for diabetes issued in 2000 by the World Health Organization (WHO) Monitor OTC sales This offers a very important opportunity. When .responding to symptoms. or to requests for OTC products for: cystitis, vaginal thrush, persistent cutaneous infections e.g. boils, styes, skin chafing under the breast, athletes foot and other fungal infections, maintain a high index of suspicion for diabetes, particularly if the condition is recurrent The pharmacist’s role in detecting undiagnosed diabetes

5. At presentation of the first prescription a. Confirm they have diabetes (in case of prescription error) and establish yourself as a source of information on diabetes care. You must know where to find the information or be able to direct the patient to the most appropriate source b. The management of prescribed medicines is a specific role for pharmacists and so it is particularly important that we fulfill this role. On receipt of the prescription, check the dosage regime and assess the prescription for any drug interactions. At presentation of a repeat prescriptiona. Check for Anomalies in the prescription : b. Hand out a short questionnairec. Remind, clarify information and educate patients in a graduated manner . General health promotion & Diabetes cared. Check on progresse. Special situationse.1 Dealing with teenagers and young adults e.2 Diabetes and minor illness Monitoring a. A source of monitoring equipmentb. Check patients’ monitoringc. Meter testingd. Encourage patients to keep appointments for check-upsRelated services a. Offer a smoking cessation service and/or link into new smoking cessation services being set up locallyb. Get involved in local medicines management projects The pharmacist’s role in the prevention of complications

6. Referral criteria • Community pharmacists should refer people with diabetes to an appropriate professional.Areas requiring referral include:Foot problems Poor glycaemic control Blurred visionWomen with diabetes who are planning a pregnancy or who have had a recent positive pregnancy test (if not already seen by a doctor)Drug addicts Patients with concerns you cannot deal with.

7. Quality assurance • It is essential to periodically review the service you provide to people with diabetes. The benefit of review is that it provides yourself other health professionals and other bodies • Ways undertaking a review include:Talking to other health professionals involved in the care of people with diabetes to see what their opinions of your service are talking to people with diabetes & their carers. • Monitoring your activity by recording team-related enquiries and referrals to other members of the  Diabetes All interventions and their outcomes The uptake of leaflets

8. Questionnaire for People with Diabetes • In our pharmacy we aim to provide a high quality service for people with diabetes and to work with the other members of the diabetes team to ensure that you receive a good standard of care. In order to help us with this, we would be grateful if you could take the time to answer a few questions about yourself and your diabetes. Your responses will be treated in strict confidence. About Yourself • How old are you ? What are your living circumstances ?How long have you had diabetes?Which of the following people have you seen about your diabetes ? • Yes No Don’t know • My GP, My hospital specialist, diabetes nurse, a Dietitian, chiropodist, optometrist .Education is a very important part of diabetes care

9. Summary of revised WHO Diagnostic Criteria for Diabetes Summary of changes The World Health Organization has published revised ‘Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications’, and Diabetes UK has recommended that all healthcare professionals adopt the new criteria from 1 June, 2000. The main changes of the new recommendations are set out below. They include the recommendation that the cut off point for diagnosing diabetes using a fasting plasma glucose should be lowered from 7.8 mmol/l to 7.0 mmol/l. This change reflects research evidence regarding the development of the complications of diabetes. Methods and criteria for diagnosing diabetes mellitus . Diabetes symptoms (ie polyuria, polydipsia and unexplained weight loss) plus a random venous plasma glucose concentration ≥ 11.1 mmol/l or a fasting plasma glucose concentration ≥ 7.0 mmol/l. (Whole blood ≥ 6.1mmol/lor 2 hour plasma glucose concentration ≥ 11.1 mmol/l 2 hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT ) . With no symptoms diagnosis should not be based on a single glucose determination but requires confirmatory plasma venous determination. At least one additional glucose test result on another day with a value in the diabetic range is essential, either fasting, from a random sample or from the two hour post glucose load. If the fasting or random values are not diagnostic the 2-hour value should be usedClassification and terminology ► The terms Type 1 and Type 2 will replace IDDM and NIDDM, and Type 1 and Type 2 process will be introduced to describe the cause of insulindependent and non-insulin dependent diabetes respectively. ► Impaired Glucose Tolerance (IGT)* is a stage of impaired glucose regulation (Fasting plasma glucose < 7.0 mmol/ and OGTT 2-hour value ≥ 7.8mmol/l but < 11.1 mmol/l). ► Impaired Fasting Glycaemia (IFG)* has been introduced to classify individuals who have fasting glucose values above the normal range but below those diagnostic of diabetes. (Fasting plasma glucose ≥ 6.1 mmol/l but < 7.0 mmol/l). Obviously some concern has been expressed about the implications of these changes for diabetes care. The new criteria have simplified the diagnosis of diabetes and the ability to diagnose cardiovascular high risk cases in many people. Earlier diagnosis will increase the total number of people with diabetes, but if they are managed according to Diabetes UK guidelines, many of these new cases will be diet controlled. In the long term, complications should be lessened to the benefit of the individual and to the health service. *IGT and IFG are not clinical entities in their own right, but rather risk categories for cardiovascular disease (IGT) and/or future diabetes.(IFG

10. The End • This information is related to Practice Guidance for Community Pharmacists on the Care of People with Diabetes ( second edition )Published by the Royal Pharmaceutical Society of Great Britain