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Names

Lawrence Daniels


Contact Details

L.Daniels@bradford.ac.uk

Required
Clinical Pharmacy and Therapeutics, 5
th
edition. Walker and
Whittlesea. Churchill Livingstone 2012. ISBN 9780702048487

NICE Clinical Guideline (CG15): Diagnosis and Management of
type 1 diabetes in children, young people and adults
http://publications.nice.org.uk/type-1-diabetes-cg15/guidance

Type 1 Diabetes: Pathophysiology and diagnosis. Clinical
Pharmacist 2013; 5:69. http://www.pjonline.com/clinical-
pharmacist/2013_apr/type_1_diabetes_pathophysiology_and_
diagnosis

Type 1 Diabetes : Insulin Management. Clinical Pharmacist 2013 ;
5 : 75. http://www.pjonline.com/clinical-
pharmacist/2013_apr/type_1_diabetes_insulin_management

NICE Clinical Guideline (CG 87): The Management of Type 2
diabetes (Quick Reference Guide)
http://guidance.nice.org.uk/CG87/QuickRefGuide/pdf/English

NICE Technology Appraisal 248. Diabetes (type 2) Exenatide
(prolonged release). February 2012.
http://publications.nice.org.uk/exenatide-prolonged-release-
suspension-for-injection-in-combination-with-oral-
antidiabetic-therapy-ta248

NICE Technology Appraisal 288 Dapagliflozin in combination
therapy for treating type 2 diabetes. June 2013.
http://publications.nice.org.uk/dapagliflozin-in-combination-
therapy-for-treating-type-2-diabetes-ta288

Optional

Diabetes requiring insulin recent developments in management
Prescriber June 2013 24(11) p.21-31
http://onlinelibrary.wiley.com/doi/10.1002/psb.1069/pdf

Type 2 diabetes: tips and pitfalls in diagnosis and management.
Prescriber October 2012; 23(26): 21-31
http://onlinelibrary.wiley.com/doi/10.1002/psb.974/pdf


MHRA Drug Safety Updates:
Insulin and Pioglitazone 2011; 4(6): A2
Unit 5 Diabetes
Student Study Guide
Medicines Optimisation
Bradford School of Pharmacy

Pioglitazone 2011; 5(1): A1
DPP-4 Inhibitors 2012; 6(2): A3
Insulin degludec 2013; 6(9): A1
All at:
http://www.mhra.gov.uk/Publications/Safetyguidance/DrugSaf
etyUpdate/index.htm




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Know how diabetes is diagnosed
Discuss the presentation, signs and symptoms of type 1 and type 2 diabetes
List the complications caused by poor control of diabetes.
Define HbA1c and know what units it is measured in
Know the characteristics of the different types of insulin preparations and give
examples of each
Explain the differences between the classes of hypoglycaemics and how they work
List the major adverse effects and clinically significant drug interactions associated
with the drug therapy of diabetes
Know how a person with diabetes who is experiencing hypoglycaemia should be
treated
Discuss the evidence for the prevention and management of the complications of
diabetes
Know the target BP for patients with diabetes
Know when aspirin and / or a statin can be prescribed to people with diabetes
Explain how pharmacists can support patients with diabetes and the main aspects of
patient education




Diabetes

Content

1. Introduction 4

2. Features and Complications 5

3. Treatment 7

4. Pharmacological Prevention of Complications 9

5. Other Complications 11

6. Role of the Pharmacist 13
















1. Introduction

Definition Diabetes is a syndrome that has hyperglycaemia as its
hallmark due to an absolute (Type 1) or relative (Type 2) lack
of insulin. Normal blood glucose of 3.5 7.0 mmol/l is
normally maintained by the actions of insulin (produced by
beta-cells in the pancreas) and glucagon (produced by the
alpha cells in the pancreas).

Aetiology The majority of cases are primary diabetes (type 1 and type
2) although secondary causes can include: pancreatic
carcinoma and haemochromatosis, liver disease, internal
insulin antagonists (e.g. growth hormone, adrenocortical
hormones and hyperthyroidism), iatrogenic causes (e.g.
corticosteroids, thiazide diuretics, protease inhibitors,
antipsychotics) and gestational diabetes. Usually the three
main abnormalities of peripheral insulin resistance, increased
glucose production from liver and reduced pancreatic
secretion of insulin are seen in type 2 diabetes.

Incidence

To access the most recent information on diabetes statistics
in the UK, read the Diabetes UK report Diabetes in the UK
2012:
https://www.diabetes.org.uk/Documents/Reports/Diabetes-in-
the-UK-2012.pdf

Diagnosis Diabetes can be diagnosed on the basis of an HbA1C
measurement or on the basis of a combination of classical
symptoms and various plasma glucose measurements. The
diagnostic criteria are at:
http://www.diabetes.org.uk/About_us/What-we-say/Diagnosis-
prevention/New_diagnostic_criteria_for_diabetes/
Ensure you can explain the following:
The diagnostic criteria for diabetes
When an HbA1C measurement should NOT be used
to diagnose diabetes
The units in which HbA1C and plasma glucose are
measured
A diagnosis of diabetes must be secure as it can affect a
persons employment, life insurance or ability to drive or
operate machinery. The DVLA standards for drivers with
diabetes https://www.gov.uk/current-medical-guidelines-dvla-
guidance-for-professionals-conditions-d-to-f covers people
driving lorries and buses for a living. How do the standards
differ from a person with diabetes riding a motorcycle?
2. Features and complications of diabetes

Features of type 1
and type 2
diabetes

Using your knowledge of the general characteristics of
diabetes complete the following table.
Type 1 Type 2
Age of onset
Body mass index
Speed of onset
Risk of ketosis
Presence of
autoantibodies

Family history

Complications


The complications of diabetes have an important impact on
morbidity and mortality and early identification of patients with
type 2 diabetes in particular is very important. Patients have
often had the condition 9-12 years before diagnosis and as
many as 50% have complications of the disease at time of
diagnosis. Strategies are therefore required to identify people
who do not know they have diabetes: NICE Public Health
Guidance (PH38) Preventing type 2 diabetes: risk
identification and interventions for individuals at high risk
http://publications.nice.org.uk/preventing-type-2-diabetes-risk-
identification-and-interventions-for-individuals-at-high-risk-
ph38
List the main complications of diabetes and their effects in the
table below:
Acute Microvascular Macrovascular






Preventing
complications

The main goals of treatment of diabetes are to prevent
complications management of diabetes significantly changed
after publication of the Diabetes Control and Complications
Trial (DCCT) in type 1 diabetes (NEJM 1993; 329: 977-86)
and the United Kingdom Prospective Diabetes Study
(UKPDS) in type 2 diabetes (Lancet 1998; 352: 854-65).
Treatment has further evolved in the light of more recent
randomised controlled trials but early control of
hyperglycaemia and particularly in type 2 diabetes
hypertension and hyperlipidaemia are still recommended.
The DCCT showed that intensive therapy delays the onset
and slows the progression of microvascular complications but
at the expense of a two to three fold increase in
hypoglycaemia. The UKPDS showed that intensive control of
hyperglycaemia reduced micro- but not macrovascular
complications whereas use of metformin rather than a
sulfonylurea of insulin reduced macro- but not microvascular
complications. However, importantly intensive control of
hypertension reduced BOTH micro- and macrovascular
complications.

Diet Whether diabetes is treated with diet alone, oral treatment or
insulin treatment should always be supported by good dietary
advice and practice. The diet recommended for people with
diabetes is basically a healthy diet, similar to the advice given
to the general population: http://www.diabetes.org.uk/MyLife-
YoungAdults/Food-and-diet/The-basics/10-steps-to-healthy-
eating/
Compare your diet on an average day with these
recommendations to see how healthy your diet is. What
adjustments do you need to make to improve it?
















3. Treatment

Insulin Insulin can be categorised based upon:
Source, e.g. beef, pork, human
Onset of action
Peak action
Duration of action
Presentation, e.g. vials, prefilled pens, cartridges to be used
with refillable pens
Strength
The objective of insulin treatment is to try to mimic normal
insulin secretion although this is usually never completely
achieved.
The currently available insulins and their categories are
available at: http://www.mims.co.uk/news/1096962/Insulin-
Preparations. Ensure that you are aware of examples of the
main categories of insulin and when they might be used and
in which combinations.
Issues with the safe use of insulin were identified by the
National Patient Safety Agency in 2010 and a Rapid
Response Report was issued in order to attempt to reduce
the number of patient safety incidents occurring with insulin
therapy. Read the report here:
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=74287 and
make a list of the interventions a pharmacist could make in
order to ensure safe use of insulin in primary and / or
secondary care.
Patients using insulin will also need to be supplied with other
items such as needles, lancets, sharps bins, blood glucose
meters, finger pricking devices etc.
Make sure you are aware how these are supplied in primary
and secondary care, for example which are available on
prescription.

Hypoglycaemia Generally defined as blood glucose < 3.5mmol/l. Most
patients using insulin or taking sulfonylureas will experience a
hypo at some time. A quarter of people who have been on
insulin for more than 5 years will have had a severe hypo
5,000 patients a year will experience hypoglycaemia on a
sulfonylurea. Symptoms of hypoglycaemia can include:
hunger, nervousness, shakiness, sweating, dizziness, feeling
light-headed, sleepiness, confusion, difficulty speaking,
feeling anxious or weak, acting as if drunk, aggressive
behaviour although these will not always be exhibited by
everybody or on every occasion. Further information on
hypoglycaemia and how to treat it is available:
http://www.nhs.uk/conditions/hypoglycaemia/Pages/Introducti
on.aspx
How would you treat a patient presenting in the pharmacy
with symptoms of hypoglycaemia?

Common causes of hypoglycaemia can include using too
much insulin or sulfonylurea, eating less carbohydrate than
usual or missing meals, taking more exercise than usual,
using a different injection site, drinking alcohol and some
other drugs.

Non-insulin
hypoglycaemics
Revise the mode of action and adverse effects of the
hypoglycaemic agents other than insulin which are available.

Ensure you are aware of the NICE guidance regarding use of
these agents at:
http://guidance.nice.org.uk/CG87/QuickRefGuide/pdf/English
and
http://publications.nice.org.uk/exenatide-prolonged-release-
suspension-for-injection-in-combination-with-oral-antidiabetic-
therapy-ta248 and
http://publications.nice.org.uk/dapagliflozin-in-combination-
therapy-for-treating-type-2-diabetes-ta288
and can state which treatments are recommended and in
which circumstances.

Complete the following table of the properties of
hypoglycaemic agents:

Medication Mechanism of
action
Effect on
weight
Adverse
effects
Metformin

Sulfonylureas

Insulin
secretagogues (e.g.
repaglinide)

Thiazolidinediones

Alpha-glucosidase
inhibitors

DPP-4 inhibitors
(gliptins)

GLP-1 agonists
(e.g. exenatide)

SGLT-2 inhibitors
(e.g. dapagliflozin)



Monitoring
diabetes

Monitoring of diabetes involves ongoing control of blood
glucose using HbA1C and blood glucose measurements.
HbA1c reflects blood glucose control over the previous 3
months and although the target will be individualised for each
person it is usually in the range 6.5% (48mmol/mol) 7.5%
(59mmol/mol). Blood glucose testing reflects current control
and recommended targets are:
pre-prandial 4-7mmol/l
post-prandial < 9mmol/l
fasting blood glucose <6mmol/L
Blood glucose monitoring is a requirement for the efficient
management of type 1 diabetes however its cost
effectiveness in type 2 diabetes has been the subject of much
debate:
http://www.medicinesresources.nhs.uk/upload/documents/Evi
dence/Medicines%20Q%20&%20A/QA367_2_SMBG_Final.d
oc
If a patient prescribed metformin alone requests advice on
self monitoring of blood glucose how would you respond?

Urine glucose testing only reflects concentration in blood a
few hours previously and provides an approximate guide to
the severity of hyperglycaemia so it not routinely used in the
management of diabetes.
All people with diabetes should have a review of their
condition at least annually and other factors should be
monitored in order to detect and / or prevent complications:
http://www.diabetes.org.uk/MyLife-YoungAdults/Treatment-
and-care/What-care-to-expect/Annual-reviews/

Other monitoring targets are as follows:
Weight - aim for BMI < 25
Blood Pressure
Target:
< 135/85mmHg (Type 1) < 140/80mmHg (Type 2)
< 130/80mmHg (Type 1 and 2) if signs of target organ
damage
Full lipid profile:
Cholesterol < 4.0mmol/l or LDL-C < 2.0mmol/l
HDL-C < 1.4mmol/l
Triglyceride < 2.3mmol/l



4. Pharmacological Prevention of Complications

Obesity Ensure you are aware of the NICE guidance for managing
overweight and obesity:
http://www.nice.org.uk/nicemedia/live/11000/30364/30364.pdf
Drug treatment should at all times be supported by dietary
changes and promotion of a healthy diet.

Blood Pressure Good control of blood pressure can reduce the risk of micro-
and macrovascular complications. NICE Clinical Guideline
CG87 Type 2 diabetes provides information on page 14 about
treatment of hypertension:
http://guidance.nice.org.uk/CG87/QuickRefGuide/pdf/English,
however NICE has since updated the Hypertension guidance
in CG127:
http://www.nice.org.uk/nicemedia/live/13561/56015/56015.pdf
. Compare these documents to check for any changes in
patients with diabetes. According to the hypertension
guidance what is the recommended first line product for the
antihypertensives denoted by the letters A, C and D?

Blood Lipids

Management of blood lipids is important to reduce the risk of
the macrovascular effects of diabetes. Pages 12-13 of the
NICE Clinical Guideline CG87 Type 2 Diabetes provides
information:
http://www.nice.org.uk/nicemedia/live/11000/30364/30364.pdf
Ensure you are aware when statins or fibrates should be
prescribed.

Anti-thrombotic
therapy
Updated MHRA advice on the use of aspirin has been added
to the NICE website at the beginning of CG87. This states:
Aspirin is not licensed for the primary prevention of vascular
events. If it is used in primary prevention, the balance of
benefits and risks should be considered for each individual
patient, particularly the presence of risk factors for vascular
disease and the risk of GI bleed. A recent meta-analysis
(ATT Collaboration, Lancet. 2009 May 30; 373(9678): 1849
1860) found aspirin did not statistically significantly reduce the
risk of major CV events and mortality in people with diabetes
and no pre-existing CV disease. Therefore prescription of
anti-thrombotic therapy should be determined on an individual
basis.



5. Other complications

Ocular
complications
Transient visual disturbances can occur due to osmotic
changes during acute hyperglycaemia but these usually
resolve when blood glucose is reduced. Longer term
complications are a source of significant morbidity with
cataracts developing earlier in patients with diabetes and the
risk of glaucoma is increased. The most serious problem
however is diabetic retinopathy which is the main cause of
blindness in the UK. This can usually be treated by laser
photocoagulation if detected early enough hence all people
with diabetes should be offered retinal screening at diagnosis
and annually thereafter.

Nephropathy In addition to hyperglycaemia, hypertension and raised
plasma lipids are risk factors for nephropathy. Therefore all
these factors require careful attention in addition to smoking
cessation (if relevant) which is another modifiable risk factor
for nephropathy. At each annual review people with diabetes
should be screened for urinary albumin concentrations and
serum creatinine to detect microalbuminuria which is a
precursor to nephropathy.
On page 15 NICE guideline CG87 gives information on the
treatment to be used when microalbuminuria is detected.
Read this guidance and decide whether the dose used for this
indication is the same as for other licensed indications of the
recommended treatment(s).

Peripheral
neuropathy
Symptoms of peripheral neuropathy include: parasthesiae,
numbness, pain, allodynia, leg cramps and an impaired sense
of position. http://www.nhs.uk/Conditions/Peripheral-
neuropathy/Pages/Introduction.aspx
Good glycaemic control will reduce the risk of problems but
people with diabetes should be advised to wear shoes that
are comfortable and do not rub, to inspect their feet regularly
for potential areas of damage, not to use potentially caustic
treatments, e.g. salicylic acid on their feet and to get
professional treatment for any foot problems. Screening for
peripheral neuropathy and a check of foot pulses and
damage to the feet is included in the diabetes annual review.
NICE guidance on the treatment of neuropathic pain was
updated in November 2013:
http://publications.nice.org.uk/neuropathic-pain-
pharmacological-management-cg173 .
What is the recommended first line treatment of neuropathic
pain for a person with diabetes?

Autonomic
neuropathy
Autonomic neuropathy is a less common result of poor
glycaemic control and may manifest as effects on the:
Cardiovascular - postural hypotension
Autonomic nervous system- gustatory sweating
Gastrointestinal system - diarrhoea; gastroparesis
Genito-Urinary system erectile dysfunction, urinary retention
Use this reference to identify a potential approach to treating
each of the four examples of autonomic neuropathy listed
above: http://www.patient.co.uk/doctor/autonomic-neuropathy




















6. Role of the Pharmacist

Before diagnosis What is the role of the pharmacist in the prevention of
diabetes and in the identification of people at risk of diabetes?
List as many examples as possible in the table below.
Prevention Identification







After diagnosis

Mr AB brings a prescription for metformin 500mg 2bd into
your pharmacy as his GP says that his blood sugar is still too
high despite his trying some dietary changes for three
months. He has been told he has diabetes and given a leaflet
about type 2 diabetes by his GP. Other than the basic dietary
advice he was given three months ago by the GP and what
he has read on the internet he doesnt really know what else
to do. He asks you for advice on how to treat his condition.
1. Make a list of all the information you need to provide to
a patient newly diagnosed with diabetes like Mr AB.
2. In order to prevent information overload what
strategies can you use to attempt to communicate this
information accurately and effectively?
3. Make a list of any different information that you would
provide to a person newly prescribed insulin (type 1 or
type 2 diabetes).
4. Make a list of the information you would provide to a
person with diabetes in order to reduce the risk of
complications.