OKA6126 NPS Diabetes Audit Guide.

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Pharmacy practice review: a counselling and action resource

Enhancing patient care in type 2 diabetes

How are you managing? Recognised by the:

Patients using an antidiabetic agent(s) with
a diagnosis of type 2 diabetes, confirmed
by the patient or their agent.
Pharmaceutical Society of Australia (PSA) CPD&PI Program for 8 credit points
Society of Hospital Pharmacists of Australia (SHPA) CPD Program for 4 hours as a group 2 activity
Australian Association of Consultant Pharmacists (AACP) as a group 2 activity for members who
are accredited pharmacists
Pharmacy Board of South Australia for up to 8 ENRICH credits.

Best practice in diabetes management

This activity will assist you to: understand and provide advice to patients on the medicines
determine and encourage adherence to antidiabetic management of diabetes and the progression to insulin
medications and ongoing lifestyle modifications to encourage patients to speak to their GP about their
prevent the long-term complications and improve diabetes management
management of diabetes identify patients who may benefit from
discuss importance of regular monitoring of HbA1c a Home Medicines Review
and reinforce recommendations of the annual cycle demonstrate provision of quality care
of care for diabetes
self-assess your abilities and practice against
reflect on priorities for patient counselling standards relevant to your role to determine
and identify counselling points training/development needs.

1. Use best practice

standards and
guidelines

Assess and encourage adherence Do I routinely check adherence to medicine(s)?

to management
Routinely check adherence to medicines
and ongoing lifestyle issues
5. Monitor progress Educate patients on the
importance of regular monitoring
Promote the importance of regular
monitoring and achievement of
blood glucose control
Individualise counselling
Gather information and check
medication records to prioritise
patients
Discuss progression of
antidiabetic treatment
Explain the progression of
treatment to insulin therapy
Provide quality care
in pharmacy practice
4. Review and reflect
What do I do to encourage adherence to medicines?
Do I encourage lifestyle modifications on an
ongoing basis?
2. Review current
Do my patients understand the meaning of HbA1c
and the importance of controlling blood glucose levels?
practice
Do I discuss with patients the importance of keeping
a record of their clinical measurements?
Do I know the recommendations of the annual cycle
of care for diabetes?
Am I gathering enough information to tailor
counselling to the individual?
Do I ensure the patient understands what
they can do to help manage their diabetes?
Are the counselling and additional support
materials I provide to patients adequate?
Do I understand the treatment options for diabetes?
Can I explain the progression to insulin therapy?
Do I ensure each patient understands their diabetes 3. Consider implementing
medication management?
changes to pharmacy
Am I offering consumer medicines information (CMI)
as required by guidelines? practice
Have I identified patients who would benefit
from a Home Medicines Review?
Do I refer patients to the GP for a review of their
diabetes to facilitate the annual cycle of care?

Guide
OKA6126 NPS Diabetes Audit Guide.qxd:Diabetes 18/4/08 12:13 PM Page 3

Additional information to assist you to review your management.

Use this information to complete the forms for patients identified as using
an oral antidiabetic agent with a diagnosis of type 2 diabetes, confirmed with
the patient or their agent.
Do not complete the form while talking to the patient. Complete as soon
as possible after your selected episode of care to reflect on your interaction with the patient.
The provision of counselling to patients with diabetes is a continuing process with many issues needing
to be reinforced on an ongoing basis. Consider focusing on 12 counselling points at each episode of care
depending on the type of prescription presentation and the stage of disease progression.

Antidiabetic medicines
Metformin has been shown to have a beneficial effect
on diabetes-related complications in overweight patients
and should be considered the drug of first choice in this
group. It is shown to reduce mortality, may reduce the
risk of cardiovascular events and is unlikely to cause
weight gain or hypoglycaemia.1
Metformin is also a suitable choice for non-overweight
patients because:
it is the only antidiabetic drug shown to reduce the
risk of diabetes-related death and all-cause mortality
unlike sulfonylureas, it does not cause weight gain
unlike sulfonylureas, it does not cause hypoglycaemia
when used alone.1
A sulfonylurea could be considered when metformin is
either contraindicated, not tolerated or for people in the
normal weight range.2 When monotherapy with metformin
(or a sulfonylurea) is insufficient, the combination of choice
is metformin plus a sulfonylurea. A thiazolidinedione can
be considered as part of this combination when:
metformin or a sulfonylurea is contraindicated
or not tolerated, or
combination therapy with metformin
and a sulfonylurea fails.
However, the use of a thiazolidinedione should not
delay the appropriate progression to insulin treatment.
More information on thiazolidinediones and their risks
is available in the December 2007 issue of NPS RADAR
(www.npsradar.org.au).
Tight control of blood glucose levels may prevent
complications of diabetes and may increase the
time until you need to start insulin many people
will require insulin eventually.
Adverse effects of thiazolidinediones2
Weight gain, oedema and fluid retention:
should not be used in patients with moderate
to severe heart failure.
Headache, dizziness, arthralgia, decrease in haemoglobin
and haematocrit, increase in total and HDL-cholesterol
(rosiglitazone).
Increased rate of fractures (among women):
rosiglitazone upper arm, hand and foot
pioglitazone arm, hand and lower leg
Potential increase in risk of myocardial infarction
with rosiglitazone. Increased risk of heart failure and
myocardial ischaemia in those already using insulin
and adding rosiglitazone.
Maintaining tight glucose control is vital for preventing
diabetic complications so starting insulin treatment should
not be delayed. There is no agreed HbA1c threshold for
starting insulin once maximal doses of oral agents fail to
maintain glycaemic control.
Insulin may be considered when:
HbA1c is 0.5% above individual target despite
optimal lifestyle and oral agents3
oral therapy alone does not provide adequate
glycaemic control
the patient is symptomatic.4
If there are no symptoms but fasting blood glucose is
consistently > 7 mmol/L (target should be individualised
for each patient), the decision is more difficult.4
Guidelines emphasise the importance of early addition
of insulin in patients who do not meet glycaemic targets
(recommended target for overall glycaemic control is
HbA1c 7%) after 3 months.3
Exercise and dietary management should be optimal and
exacerbating factors excluded, e.g. concurrent infection
and other agents that may affect glycaemic control
(especially corticosteroids).4,5

2
OKA6126 NPS Diabetes Audit Guide.qxd:Diabetes 18/4/08 12:13 PM
Controlling blood glucose levels
Diabetes is essentially a self-managed disease and requires
patients to be self-motivated to achieve optimal diabetes
management.6
Adherence
Routinely check pharmacy medication history as part of
the dispensing process and assess and monitor adherence.7
Patients often have comorbidities and these make their
medication regimen more complex and often difficult
to adhere to.6 Adherence rates to oral antidiabetic agents
has been reported as 65% to 85% compared with 75%
to 90% for blood pressure and cholesterol-modifying
medication.8 In general, the more complex a medication
regimen the less likely the patient is to be adherent.
Pharmacist interventions including diabetes education,
medication counselling and lifestyle modification have
been shown to have a beneficial effect on HbA1c levels.9,10
To improve non-adherence to medicines try to determine
the cause of non-adherence, both intentional (e.g. health
beliefs including perceived seriousness of diabetes,
vulnerability to complications and efficacy of treatment
and lifestyle factors) and unintentional e.g. lack of
knowledge, forgetfulness.
We all forget to take our medicines sometimes
How many doses have you forgotten in the last week?
Strategies for improving adherence
to diabetes management6
Provide education about diabetes, its management
and the complications associated with diabetes.
Discuss the benefits of medication and how to manage
adverse events if they arise.
Medication review should be done regularly.
Ensure the patients blood glucose monitor is working
correctly and that they are using it appropriately.
In conjunction with the doctor, help the patient
achieve and understand their blood glucose
(or HbA1c) targets.
Ensure other comorbidities are being adequately treated.
Ensure appropriate preventative therapies are being
prescribed and adhered to.
Consider providing a dose administration aid.
3
Page 4
Blood glucose levels
Long-term glycaemic control is monitored by measuring
glycated haemoglobin (HbA1c). The United Kingdom
Prospective Diabetes Study (UKPDS) showed reduced
incidence and progression of diabetes-related
complications in subjects with a lower HbA1c.
The recommended target for overall glycaemic control
is HbA1c 7%, however, this should be individualised as
this may not be appropriate in the elderly.4 HbA1c should
be measured at least 6-monthly (see Table 1, page 6).4
Random blood glucose levels should be monitored every
34 months if the patient is not self-monitoring and
has an elevated HbA1c or is experiencing hypoglycaemia
(see Tables 1 and 2, page 6).4
Self-monitoring of blood glucose levels
Self-monitoring is desirable; the method and frequency
of testing should be individualised after initial close
supervision, and is extremely important once insulin
therapy is started.
Initial schedule: 34 times daily (early morning plus
other tests before and after meals).4
Maintenance schedule: 14 times a day, at different
times of the day on 13 days of the week.2,4,5
In elderly patients: on 1 or 2 days of the week, varying
in time, may be adequate.4
Extra tests should be performed when the patient's
normal routine is changed, e.g. during illness, travelling
or changes in diet. Frequent consultation with healthcare
professionals is important.
Check that the patient is competent at blood glucose
monitoring as treatment decisions may be based on these
readings.4 Encourage patients to record their blood glucose
readings and assist them in interpreting the pattern of their
readings.
Would you like some information on your goals
for managing your diabetes?
Offer written patient information
Managing your type 2 diabetes
your goals
OKA6126 NPS Diabetes Audit Guide.qxd:Diabetes 18/4/08 12:13 PM Page 5

Controlling blood glucose levels (continued...)

How to manage hypoglycaemia Lifestyle advice
Hypoglycaemia, or low blood glucose, may be due to Lifestyle advice should be repeated and reinforced
excessive insulin, a sulfonylurea or repaglinide, deficient to optimise the reduction in overall cardiovascular risk
carbohydrate intake or unaccustomed exercise.4 (see Table 1, page 6). A multidisciplinary approach
providing consistent advice is important.4 A combined
Use some quick acting carbohydrate that is easy program of healthy eating, physical activity and education
to consume: directed at behaviour change is often successful. Social
half a can of regular soft drink and carer suppport is associated with better adherence
to management and behaviour change.4,6
half a glass of fruit juice
3 teaspoons of sugar or honey Refer to:
67 jelly beans Diabetes Australia: www.diabetesaustralia.com.au
or 1300 136 588 for patient information.
glucose tablet equivalent to 15 g carbohydrate.
Dieticians Association: 1800 812 942 for dieticians
Followed by a longer acting carbohydrate:
in your local area.
a sandwich
Heart Foundation: www.heartfoundation.org.au
a glass of milk
or 1300 362 787 for patient information.
a piece of fruit
6 small dry biscuits and cheese
It is really important to look after yourself
23 pieces of dried fruit when you have diabetes:
a tub of natural low fat yoghurt. 1. Quit smoking
See www.diabetesaustralia.com.au for a patient 2. Minimise alcohol consumption
information leaflet. 3. Be active
4. Eat healthy foods.
Drugs that may affect glycaemic control
Table 3 (page 6) shows some of the most frequently
encountered agents that have the potential to affect Patient
Information
Leaflet
Offer written patient information
glycaemic control. These are unlikely to be a problem in Managing your type 2 diabetes
your lifestyle

Managing your type 2 diabetes

improve your blood glucose,
you control your diabetes and
Simple lifestyle changes can help and kidneys from disease.
and help protect your eyes, feet
blood pressure, cholesterol levels
Physical activity
Stop smoking

patients already stabilised on both drugs. Monitor closely

maintain a
Exercise is vital to
the risk of heart
If you have diabetes and smoke, healthy lifestyle. By becoming
losing limbs is
disease, stroke and the risk of more active you can improve
your risk reduces.
increased. If you stop smoking, your general health,
quality of life and
Where do I go to quit?
diabetes management.

your lifestyle
give you support
Your pharmacist or doctor can
and refer you to other places to
help you. Aim for at least
provides 30 minutes of
The Quitline 13 QUIT (13 7848) moderate-intensity
counselling over the phone. physical activity on

when changing dosing or starting new agents.

You can ring Quitline at any time most days of the
of the day or night. week and resistance
training 2 to 3 times
breathing and
Healthy eating a week. You should notice your
a light sweat,
your blood heart rate speeding up and perhaps
Healthy eating can help control to talk. Try
fats) and blood however you should still be able
pressure, cholesterol level (blood enjoy taking
from being walking or gardening. Some people
glucose level by preventing you a class in strength-based training,
dancing, water
in your heart.
overweight or having fatty deposits aerobics or Tai Chi. You can add
up your activity:
same as one
Everyone, including people with
diabetes can three 10 minute sessions is the
There is no 30 minute session.
benefit from eating healthy foods.
diet but if you
need for separate meals or a special Stop exercising if you experience
shakiness,
are recommended. palpitations, chest
are overweight smaller meals tingling lips, hunger, weakness,
breathing.
Most importantly enjoy a wide
variety pain, light headedness or difficulty
of nutritious foods: before starting
Be sure to check with your doctor
Eat plenty of vegetables, legumes
and fruit any new physical activity program.
adults is
(Recommended daily amount for
of fruit. A serve Moderate alcohol consumption
5 serves of vegetables + 2 serves
vegetables
of vegetables is 1/2 a cup of cooked Alcohol increases your likelihood
of being
mixed vegetables
e.g. broccoli, carrot, stir-fry or overweight and developing heart
disease. It
or 1 cup of salad) can increase your blood glucose
levels. Most
breads, rice, a moderate
Eat plenty of cereals (including people with diabetes can enjoy
wholegrain
pasta and noodles), preferably amount of alcohol.
poultry
Include lean meat, fish and/or In general, the maximum amount
of alcohol
cut the visible fat off your meat recommended for people with
diabetes is
(for men
Include milks, yoghurts, cheeses
(moderate 2 standard drinks or less per day
fat
amounts) and/or alternatives. Reduced or women).
possible
varieties should be chosen where
Drink plenty of water
and sugary
Limit takeaway foods and fatty
foods like sausages and cakes.

Please turn over

Medicines to help prevent cardiovascular complications

Diabetes is an independent risk factor for both macro- and microvascular disease. Improved glycaemic and blood pressure
control has been shown to reduce microvascular complications.4,11 Reduction of macrovascular complications depends on
glycaemic control and modification of other risk factors such as smoking, hypertension and dyslipidaemia.4

Hypertension ACE inhibitors, beta blockers and low-dose thiazide diuretics

Early detection, active treatment and frequent review
of BP are essential to reduce morbidity (see Table 1,
page 6, for target levels and monitoring). Encourage
non-pharmacological measures e.g. ideal weight, regular
exercise and minimisation of salt and alchohol intake.4
Regular monitoring and control of your blood
pressure and cholesterol (blood fat) is important
to prevent complications of your diabetes.
are antihypertensive agents of choice in people with both
diabetes (without renal disease) and hypertension.2 ACE
inhibitors are associated with reduced proteinuria and
slowing of the rate of progression of renal failure in patients
with renal disease, in particular those with type 1 diabetes
and diabetic nephropathy.2 Angiotensin II-receptor
antagonists have been shown to delay progression of renal
disease in people with type 2 diabetic nephropathy.12,13
Offer written patient information
Managing your type 2 diabetes
your goals

4
OKA6126 NPS Diabetes Audit Guide.qxd:Diabetes 18/4/08 12:13 PM
Medicines to help prevent cardiovascular complications (continued...)
Dyslipidaemia
Lipid abnormalities are common in patients with
diabetes. Dyslipidaemia is an independent risk factor
for macrovascular complications.
Recommendations for treatment, following interventions
to modify lifestyle and improve blood glucose control:
(see Table 1, page 6, for target levels and monitoring)
LDL-cholesterol > 2.5 mmol/L: statin treatment
triglycerides > 2.0 mmol/L: fibrate treatment.14
If patients are not achieving target lipid levels check
adherence to medications, as a high rate of non-adherence
with statins has been reported.15
Counselling encounter
Providing written information
Consumer medicine information (CMI) can be used to
supplement verbal counselling.7 CMI may be offered to the
patient each time a product is dispensed.17 Whether this is
appropriate is a matter for professional judgement.
Counselling
Counselling provided to the patient or their agent
should be done in a way that is sensitive to privacy
and confidentiality to encourage full discussion.
Summary of planned actions
Identify any further actions that need to be implemented
for the patient. Use the Counselling checklist and action
plan enclosed to:
record the counselling already provided to the patient to
determine subsequent counselling to be provided at the
next episode of care
detail planned actions for individual patients that you
may wish to implement or address at the next episode
of care.
5
Page 6
Aspirin therapy
Low-dose aspirin (75150 mg) should be considered
for people with type 2 diabetes where no absolute
contraindication exists.2,5,16
Weigh up the potential cardiovascular benefits verses
bleeding risk before starting aspirin therapy.
What other medicines do you take?
Are you taking aspirin? ask your doctor about
the possible benefit of aspirin.
CMIs should generally be provided:
when a medicine is first provided to the patient
on provision of a medicine when:
- a significant change to the CMI has been notified
by a sponsor (medicine manufacturer)
- the dosage form has been changed
(e.g. to a once-daily formulation)
- brand substitution occurs and providing
the CMI is deemed appropriate
with each supply of a medicine for which there are
valid reasons for regular reinforcement of information
at the patients/carers request
when the patient has special needs
at regular intervals for medicines used for long-term
therapy (e.g. every 6 months).
You may prefer to use patient records or specific
documentation that you already use.
Flag your dispensing software to
identify patients for further counselling
or planned actions to be implemented.
OKA6126 NPS Diabetes Audit Guide.qxd:Diabetes 18/4/08 12:13 PM Page 7

Table 1 Goals for optimal management and monitoring of diabetes2,4,5,18,19

Goals for optimum management Recommended frequency of monitoring

Cigarette consumption Zero
Alcohol intake* 4 standard drinks (40 g)/day (men)
2 standard drinks (20 g)/day (women)
Physical activity At least 30 minutes walking (or equivalent) on
5 or more days/week (Total 150 minutes/week).
Resistance training using moderate weights and high
repetitions can be part of an exercise program 3 monthly, once control is achieved
BMI < 25 kg/m where practical
2

Waist circumference < 94 cm (men), < 80 cm (women)

Blood pressure < 125/75 mmHg
if proteinuria > 1 g/day
< 130/80 mmHg (< 130/85 mmHg)
if proteinuria 1 g/day
Blood glucose level 46 mmol/L (fasting) 34 monthly if patient not self-monitoring and
elevated HbA1c or experiencing hypoglycaemia
HbA1c 7% At least 6 monthly, once control is achieved
Total cholesterol < 4.0 mmol/L
LDL-cholesterol < 2.5 mmol/L
HDL-cholesterol > 1.0 mmol/L
Annually if below target, and more frequently
Triglycerides < 1.5 mmol/L
if the patient is being actively treated
Urinary albumin excretion < 20 microgram/min (timed overnight collection)
< 20 mg/L (spot collection)
albumin:creatinine ratio < 3.5 mg/mmol (women)
< 2.5 mg/mmol (men)
* NHMRC recommend 2 standard drinks or less per day for both men and women.20
There are inconsistencies in guideline recommendations for patients with diabetes and proteinuria 1 g/day.
Specific guidelines for diabetes recommend a target blood pressure of < 130/80 mmHg.

Table 2 Target blood glucose levels4

Preprandial Postprandial
blood glucose (mmol/L) blood glucose (mmol/L) Comment
4.06.0 4.07.7 Normoglycaemia
6.16.9 7.811.0 Minimises microvascular problems
7.0 11.1 Associated with microvascular and macrovascular complications.
Consider more active treatment
> 8.0 > 20.0 Generally prompts further and more active treatment

Table 3 Drugs that may affect glycaemic control2

Drugs which may decrease

blood glucose levels Drugs which may increase blood glucose levels
alcohol atypical antipsychotics nicotinic acid (lipid-lowering doses)
aspirin (high doses) (e.g. clozapine, olanzapine, quetiapine, risperidone) oral contraceptives (combined)
disopyramide baclofen phenytoin
perhexilene chlorpromazine protease inhibitors
quinine cyclosporin tacrolimus
trimethoprim with glucocorticoids thiazide diuretics
sulfamethoxazole haloperidol (high dose e.g. hydrochlorothiazide 50 mg)
hormone replacement therapy (HRT) tricyclic antidepressants (TCAs)
This is not a complete list see AMH 2008.2
Note: beta blockers may mask some hypoglycaemic warning signs and increase incidence and severity of hypoglycaemia but data are conflicting.2

6
OKA6126 NPS Diabetes Audit Guide.qxd:Diabetes 18/4/08
Pharmacist competencies
Participation in this activity may help you address the following competency standards.21
Functional Area
(areas of responsibility for practising pharmacists)
1: Practice pharmacy in a professional and ethical manner
2: Manage work issues and interpersonal relationships
in pharmacy practice
3: Promote and contribute to optimal use of medicines
4: Dispense medicines
6. Provide primary health care
7: Provide medicines and health information and education
8: Apply organisational skills in the practice of pharmacy
12:13 PM Page 8
Competency Unit (areas of professional performance)
1.2: Practise to accepted standards
1.3: Pursue lifelong professional learning and contribute
to the development of others
2.1: Apply communication skills
2.3: Address problems
3.1: Participate in therapeutic decision making
3.2: Provide ongoing pharmaceutical management
4.2: Evaluate prescribed medicines
4.3: Supply prescribed medicines (element 3: assist patient understanding
and adherence)
6.1: Assess primary health care needs
6.2: Address primary health care needs of patients
6.3: Promote good health in the community
7.3: Disseminate information (element 2: provide information to assist
patient care, and element 3: educate members of the general public)
8.1: Plan and manage work time
8.4: Work in partnership with others
7
OKA6126 NPS Diabetes Audit Guide.qxd:Diabetes 18/4/08 12:13 PM Page 1

Confidentiality and privacy

What will happen to your patient data What will happen to your personal details
Your de-identified patient data forms are scanned Your personal details are:
and returned to you.
provided to a mail house for processing
Your individual results are kept confidential
and are provided to you only. recorded for NPS evaluation
Your data are aggregated with those of other provided to the Pharmaceutical Society of Australia
participants and the aggregate results (which do for CPD & PI credit point allocation, if appropriate
not identify any individual patient or pharmacist): provided to your intern course co-ordinator
are provided to all participants to confirm completion, if appropriate
may be used in NPS evaluation and reports. available from NPS by request in writing.

At the close of the review cycle (i.e. after individual results Please note: You are responsible for advising NPS
are returned to participants), all potentially identifying data of any changes of address during the audit cycle
are removed from NPS records. Your individual results will
then no longer be available. Further information
Therapeutic enquiries
Contact Sheena ORiordan or Michelle Koo
Phone (02) 8217 8700

References
1. UK Prospective Diabetes Study (UKPDS) Group.
Effect of intensive blood-glucose control with
metformin on complications in overweight patients
with type 2 diabetes (UKPDS 34). Lancet
1998;352:85465.
2. Australian Medicines Handbook, 2008.
3. Nathan DM, Buse JB, Davidson MB, et al.
Management of hyperglycemia in type 2 diabetes:
a consensus algorithm for the initiation and
adjustment of therapy: a consensus statement
from the American Diabetes Association and the
European Association for the Study of Diabetes.
Diabetes Care 2006;29:196372.
4. Diabetes management in general practice
Guidelines for type 2 diabetes, 2007/8.
Diabetes Australia, 2007.
5. Therapeutic Guidelines: Endocrinology,
version 3. 2004.
6. Pharmaceutical Society of Australia (PSA). Essential
CPE: Medication adherence. Canberra: PSA, 2006.
7. PSA. Professional Practice Standards,
Version 3. Canberra: PSA, 2006.
8. Rubin RR. Adherence to pharmacological therapy
in patients with type 2 diabetes mellitus.
Am J Med 2005;118 Suppl 5A:27S34S.
9. Machado M, Bajcar J, Guzzo GC, et al. Sensitivity of
patient outcomes to pharmacist interventions. Part I:
Systematic review and meta-analysis in diabetes.
Annals Pharmacother 2007;41:156982.
10. Nkansah NT, Brewer JM, Connors R, et al. Clinical
outcomes of patients with diabetes mellitus
receiving medication management by pharmacists
in an urban private physician practice.
Am J Health Syst Pharm 2008;65:1459.
11. UKPDS Group. Tight blood pressure control and risk
of macrovascular and microvascular complications in
type 2 diabetes (UKPDS 38). BMJ 1998;317:70313.
12. Lewis EJ, Hunsicker LG, Clarke WR, et al.
Renoprotective effect of the angiotensin-receptor
antagonist irbesartan in patients with nephropathy
due to type 2 diabetes. N Engl J Med 2001;
345:85160.
13. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects
of losartan on renal and cardiovascular outcomes
in patients with type 2 diabetes and nephropathy.
N Engl J Med 2001;345:8619.
14. National Heart Foundation of Australia and the
Cardiac Society of Australia and New Zealand.
Position Statement on Lipid Managment.
Heart Lung Circ 2005;14:27591.
15. Simons LA, Simon J, McManus P, et al.
Discontinuation rates for use of statins are high.
BMJ 2000;321:1084.
16. National Health and Medical Research Council
(NHMRC). National evidenced based guidelines
for the management of type 2 diabetes mellitus:
prevention and detection of macrovascular disease
in type 2 diabetes. NHMRC, 2004.
17. PSA. Consumer medicines information and the
pharmacist - Guidelines for pharmacists.
Canberra: PSA, 2007.
18. National Heart Foundation of Australia and Cardiac
Society of Australia and New Zealand. Hypertension
management guide for doctors, 2004. National
Heart Foundation of Australia, 2004.
19. Therapeutic Guidelines: Cardiovascular,
version 4. 2003.
20. NHMRC. Australian alcohol guidelines for
low risk drinking: Draft for public consultation.
NHMRC, 2007.
21. PSA. Competency standards for pharmacists
in Australia 2003. Canberra: PSA, 2003.

April 2008
The information contained in this material is derived from a critical analysis of a wide range of authoritative evidence.
Any treatment decisions based on this information should be made in the context of the clinical circumstances of each patient.

NPSA0785

National Prescribing Service Limited ACN 082 034 393

An independent, non-profit organisation for Quality Use of Medicines,
funded by the Australian Government Department of Health and Ageing.
Level 7 / 418A Elizabeth Street Surry Hills NSW 2010
Phone: 02 8217 8700 l Fax: 02 9211 7578 l email: info@nps.org.au l web: www.nps.org.au
OKA6294 NPS PIL Pad Ph Audit GOALS.qxd:Your Goals 17/4/08
Managing your type 2 diabetes your goals
You can control your diabetes by maintaining blood glucose, blood pressure and cholesterol levels
that are as close to normal as possible. Managing your diabetes also includes feet, urine, eye and
dental checks. By regularly checking these you can slow or prevent further complications including
heart disease, kidney disease, blindness, nerve damage and gum disease.
Blood glucose levels (BGL)
Regularly testing your own blood glucose levels
can let you know about your bodys response
to things like medications, food,
exercise and your general health.
Your doctor, diabetes educator,
practice nurse or specialist will
help you decide how many tests
are needed, when to test
your blood and the
levels to aim for.
PL
The target range
is usually around
M
4 to 8 mmol/L.
HbA1c (glycated haemoglobin)
SA
This test shows the average of your blood glucose
level (BGL) over the past 1012 weeks. It does not
show the highs and lows but gives an overall
picture of your blood glucose management.
High blood glucose levels contribute to the
development of long-term complications
of diabetes.
It is best have your HBA1c level re-tested
at least every 6 months.
The target level is usually around 7% or lower.
Blood pressure (BP)
This is the measurement of the pressure at which
your heart pumps blood around the body.
High blood pressure can increase the risk of heart
disease, stroke and kidney disease.
It is best to have your blood pressure checked
regularly (at least every three months).
1:44 PM Page 1
Patient
Information
Leaflet
Your blood pressure can be treated with medicines
if necessary.
When blood pressure is taken it is measured
in millimetres of mercury (mmHg). The reading
is recorded as two numbers.
For someone with diabetes, the target is usually
less than 130/80 (stated as 130 over 80).
Cholesterol (blood fats or lipids)
E
This is a type of fat in the blood. Cholesterol
problems are common in people with diabetes
and too much fat increases the risk of heart
disease and stroke.
The target total cholesterol level is usually
less than 4 mmol/L.
There are two types of cholesterol low-density
lipoproteins (LDLs, or bad cholesterol) and high-
density lipoproteins (HDLs, or good cholesterol).
LDL-cholesterol can narrow or block your blood
vessels. Keeping your LDL low helps protect
your heart.
The target LDL level is usually
less than 2.5 mmol/L.
HDL-cholesterol helps remove deposits from your
blood vessels and stops them getting blocked.
The target HDL level is usually
above 1 mmol/L.
Triglycerides are another type of fat in your blood.
The target triglyceride level is usually
less than 1.5 mmol/L.
It is best to have your cholesterol levels tested
at least every 12 months.
Cholesterol levels can be improved with
lifestyle changes which may reduce your
need for medication.
Please turn over
OKA6294 NPS PIL Pad Ph Audit GOALS.qxd:Your Goals 17/4/08 1:44 PM Page 2

Managing your type 2 diabetes your goals continued...

You can reduce the risk of eye, foot and kidney damage by keeping your BGL, HbA1c
and BP at recommended target levels.

Eyes Questions to ask your doctor

Diabetes can cause eye problems including What are my current numbers for:
cataracts, glaucoma and retinopathy, and may
lead to blindness. blood glucose? _____________________
Many people don't notice any problems with
their sight until their eyes are already damaged. HbA1c? _____________________

If you notice any changes in your vision, tell your

blood pressure? _____________________
doctor or eye specialist as soon as possible.
It is best to have your eyes checked cholesterol? _____________________
at least every one to two years.
What numbers should I be aiming for:
Feet
People with diabetes can develop a number of blood glucose? _____________________
foot problems such as changes to the skin, calluses,
foot ulcers and nerve damage (neuropathy). Foot HbA1c? _____________________
problems can lead to amputation.
It is important to take good care of your feet blood pressure? _____________________
E
and be aware of any changes. Check your feet
every day as instructed by your podiatrist cholesterol? _____________________
PL

or diabetes educator.
What should I do to reach these goals?
It is best to have a foot examination every
12 months by your doctor or podiatrist. _________________________________________________
M

Urine/kidneys _________________________________________________
SA

Over time, people with diabetes face increased

_________________________________________________
risk of damage to their kidneys (nephropathy).
An early sign of kidney problems can be detected _________________________________________________
through a urine test for microalbumin.
It is best to have your urine checked every _________________________________________________
12 months for microalbumin.
_________________________________________________
Teeth/gums
High blood glucose levels can make a person more
likely to have infections. In the mouth both teeth
and gums can be affected. Even a poorly fitted
denture can cause an ulcer.
It is best to have your mouth checked
every 12 months by a dentist.

This leaflet has been provided to you by your pharmacist to help discuss how best to manage your diabetes.
April 2008
We acknowledge the assistance of Diabetes Australia NSW in the review of this resource.

NPS is an independent, non-profit organisation for Quality Use of Medicines,

funded by the Australian Government Department of Health and Ageing.
ABN 61 082 034 393 l Level 7/418A Elizabeth Street Surry Hills NSW 2010 l PO Box 1147 Strawberry Hills NSW 2012
Phone: 02 8217 8700 l Fax: 02 9211 7578 l email: info@nps.org.au l web: www.nps.org.au
NPSE0812
OKA6294 NPS PIL Pad Ph Audit LIFESTYLE.qxd:Your Lifestyle 17/4/08 1:45 PM Page 1

Patient
Information
Leaflet
Managing your type 2 diabetes your lifestyle

Simple lifestyle changes can help you control your diabetes and improve your blood glucose,
blood pressure, cholesterol levels and help protect your eyes, feet and kidneys from disease.

Stop smoking Physical activity

If you have diabetes and smoke, the risk of heart Exercise is vital to maintain a
disease, stroke and the risk of losing limbs is healthy lifestyle. By becoming
increased. If you stop smoking, your risk reduces. more active you can improve
your general health,
Where do I go to quit? quality of life and
Your pharmacist or doctor can give you support diabetes management.
and refer you to other places to help you. Aim for at least
The Quitline 13 QUIT (13 7848) provides 30 minutes of
counselling over the phone. moderate-intensity
You can ring Quitline at any time physical activity on
E
of the day or night. most days of the
week and resistance
PL

training 2 to 3 times
Healthy eating a week. You should notice your breathing and
Healthy eating can help control your blood heart rate speeding up and perhaps a light sweat,
M

pressure, cholesterol level (blood fats) and blood however you should still be able to talk. Try
glucose level by preventing you from being walking or gardening. Some people enjoy taking
SA

overweight or having fatty deposits in your heart.
Everyone, including people with diabetes can
benefit from eating healthy foods. There is no
need for separate meals or a special diet but if you
are overweight smaller meals are recommended.
Most importantly enjoy a wide variety
of nutritious foods:
Eat plenty of vegetables, legumes and fruit
(Recommended daily amount for adults is
5 serves of vegetables + 2 serves of fruit. A serve
of vegetables is 1/2 a cup of cooked vegetables
e.g. broccoli, carrot, stir-fry or mixed vegetables
or 1 cup of salad)
Eat plenty of cereals (including breads, rice,
pasta and noodles), preferably wholegrain
Include lean meat, fish and/or poultry
cut the visible fat off your meat
Include milks, yoghurts, cheeses (moderate
amounts) and/or alternatives. Reduced fat
varieties should be chosen where possible
a class in strength-based training, dancing, water
aerobics or Tai Chi. You can add up your activity:
three 10 minute sessions is the same as one
30 minute session.
Stop exercising if you experience shakiness,
tingling lips, hunger, weakness, palpitations, chest
pain, light headedness or difficulty breathing.
Be sure to check with your doctor before starting
any new physical activity program.
Moderate alcohol consumption
Alcohol increases your likelihood of being
overweight and developing heart disease. It
can increase your blood glucose levels. Most
people with diabetes can enjoy a moderate
amount of alcohol.
In general, the maximum amount of alcohol
recommended for people with diabetes is
2 standard drinks or less per day (for men
or women).

Drink plenty of water

Limit takeaway foods and fatty and sugary
foods like sausages and cakes.

Please turn over

OKA6294 NPS PIL Pad Ph Audit LIFESTYLE.qxd:Your Lifestyle 17/4/08 1:45 PM Page 2

Know about your medicines

Know how your medicines help you. Understand how your medicines work, what side effects
they may have and how they interact with other medicines that you are taking.
You may use medicines to make you feel better, others might stop your diabetes from getting
worse or prevent complications from arising or they could be for another condition altogether.

Medicines dont just come on prescription. You For more information

can also get medicines that are recommended by
a pharmacist. You might choose medicines yourself
from the chemist or pharmacy, a supermarket or
a health food shop (herbal or natural medicines).
Knowing your medicines will help you to choose
the right medicine, get better results from them,
avoid side effects where possible and enjoy
better health.
You may take a lot of medicines
and this can make it difficult to
remember which medicine you
need to take and what time it
needs to be taken. It is important
to talk to your pharmacist
or doctor about all your
PL
Download or order free resources from National
Prescribing Service Limited at www.nps.org.au
or order on 02 8217 8700.
National Prescribing Service Limited provides
free medicines information:
Medicines Line 1300 888 763 independent
information on your medicines
Medicines List a sheet for you to record
your medicines
Consumer Medicines Information (CMI)
important facts about medicines
E
Seniors find out how to book a free medicines

medicines and any information session on 02 8217 8724

concerns you have with
Fact sheets including, What is a medicine?
managing any of them.
Generic medicines, Remembering your medicines
M

It can help to know:

Medimate helps you find, understand and
use information about medicines (4 languages).
SA

what the medicine is for

how much you use and how often Diabetes Australia State and Territory organisations
what times of the day you use it provide useful general information and resources
about type 2 diabetes and its management
what to do if you miss a dose
including the use of medicines.
side effects to watch out for and what
to do if you get a side effect Contact Diabetes Australia at
www.diabetesaustralia.com.au or the Diabetes
any special instructions, for instance before Australia office in your State on 1300 136 588.
or after meals.
Ask your pharmacist or doctor to help you maintain
a list of all your medicines.

This leaflet has been provided to you by your pharmacist to help discuss how best to manage your diabetes.
April 2008
We acknowledge the assistance of Diabetes Australia NSW in the review of this resource.

NPS is an independent, non-profit organisation for Quality Use of Medicines,

funded by the Australian Government Department of Health and Ageing.
ABN 61 082 034 393 l Level 7/418A Elizabeth Street Surry Hills NSW 2010 l PO Box 1147 Strawberry Hills NSW 2012
Phone: 02 8217 8700 l Fax: 02 9211 7578 l email: info@nps.org.au l web: www.nps.org.au
NPSE0813
OKA6126 NPS DIAB PA DataForm.qxd:Diabetes Data Form 18/4/08 12:38 PM Page 1

Enhancing patient care

in type 2 diabetes
Use a black biro to mark a cross (X) in the box beside your NPS office use only
response. If you make a mistake, use white correction fluid.
Do not complete this form while talking to the patient.
Complete as soon as possible after the episode of care.

Episode of care and antidiabetic medicines

1. Who was involved in this episode of care? the patient relative/carer/support person
AND community pharmacist accredited pharmacist hospital pharmacist intern pharmacist
2. Age of patient: 50 years > 50 years
3. Current antidiabetic agent(s) used (mark all that apply): 5. Indicate what verbal counselling you provided
at this episode of care (mark all that apply):
acarbose repaglinide

Mark these on Couselling checklist

purpose of antidiabetic medicines
glibenclamide rosiglitazone
Ensure understanding of importance of diabetes control
gliclazide insulin to prevent long-term complications.
glimepiride Fixed-dose how to take/use antidiabetic medicines
glipizide combination products Provide details on dose, timing and special instructions
metformin/glibenclamide to optimise adherence.
metformin
metformin/rosiglitazone possible adverse effects of medicines
pioglitazone
Discuss potential for and how to manage adverse effects
4. Was the presenting prescription for antidiabetic agent(s): of antidiabetic medicine(s).
Thiazolidinediones: may increase risk of heart failure,
the first ever antidiabetic medicine used
myocardial ischaemia and fractures (see Guide page 2).
ongoing therapy
response to therapy
SA

a change or addition to ongoing therapy Ensure understanding of how response to antidiabetic treatment
not determined is assessed and discuss strategies to manage hypoglycaemia.
M

Controlling blood glucose levels

PL

6. How did you assess adherence with antidiabetic medicines?

Regularly check dispensing records to monitor adherence.
not applicable (first dispensing) dose administration aid returns
Discuss with patient we all forget to take our medicine(s)
E

dispensing of repeat prescriptions not assessed sometimes. How many doses have you forgotten in the last week?
open questioning other ___________________
12. Indicate what verbal counselling you provided
7. Was the patient using any other medicines that may at this episode of care (mark all that apply):
affect control of blood glucose? (see Guide, page 6) importance of adherence to medicines
Mark these on Couselling checklist

yes no not determined Consider strategies to assist adherence. (see Guide, page 3)

8. Did the patient self-monitor blood glucose levels? potential interactions with other medicines.
Remind patient of need to check with doctor or pharmacist
yes no not determined
for potential drug interactions.
Were levels recorded? how to manage hypoglycaemia (see Guide, page 4)
yes no not determined Remind patient of symptoms and use of
quick acting carbohydrate.
9. Had the patient had their HbA1c measured
by their GP within the last 6 months? need for ongoing monitoring
Discuss meaning of HbA1c and blood glucose levels.
yes no not determined unknown
Self-monitoring needs to be recorded for GP to review.
10. Did the patient know their HbA1c measurement? Stress importance of regular checking and achievement of targets.
yes no not determined importance of ongoing lifestyle modification
Early and continued lifestyle changes reduce overall
11. Had the patient had their weight or waist circumference
cardiovascular risk and disease progression.
measured by their GP within the last 34 months?
yes no not determined unknown 13. What ongoing lifestyle advice has been provided?

none minimise salt intake

Target blood glucose levels: 46 mmol/L (fasting)
Encourage self-monitoring: frequency should be individualised quit smoking reduce weight
to reflect therapeutic aims. healthy eating reduce saturated fat
Target HbA1c levels: 7% (measure HbA1c at least 6 monthly)
high-fibre/low reduce sugar intake
Needs to be regularly measured and is assessed when considering
glycaemic index diet
initiation of insulin. regular moderate exercise
Target BMI: < 25 kg/m2 minimise alcohol intake other ___________________
Target waist circumference: < 94 cm (male), < 80 cm (female)
Please turn over to continue
OKA6126 NPS DIAB PA DataForm.qxd:Diabetes Data Form 18/4/08 12:38 PM Page 2

Medicines to help prevent cardiovascular complications

14. Current antihypertensive agent(s) (mark all that apply):

Assess coexisting conditions
Single agents Fixed-dose combination products Multiple morbidities/conditions are often present.
none thiazide + ACE inhibitor
Remind patient to take medicines regularly to ensure optimal
ACE inhibitor thiazide + angiotensin management of cardiovascular risk factors.
II-receptor antagonist
angiotensin II-receptor antagonist Ensure understanding of the importance of regular BP and lipid
felodipine + ramipril measurements, and assessment of microalbuminuria.
beta-blocker
amlodipine + atorvastatin
calcium-channel blocker
thiazide/thiazide-like diuretic
other ___________________________________________

15. Current lipid-modifying agent(s) (mark all that apply):

Single agents Fixed-dose combination products
none ezetimibe atorvastatin + amlodipine
fibrate (fenofibrate, gemfibrozil) simvastatin + ezetimibe
HMG-CoA reductase inhibitor (statin)
other ___________________________________________

16. Current antiplatelet agent(s) (mark all that apply):

For patients not using aspirin, remind them to ask their doctor about
none clopidogrel ticlopidine their benefits of using aspirin to reduce their risk of ischaemic heart
aspirin (low-dose) dipyridamole aspirin + dipyridamole disease and preventing stroke.

17. Other medicines: (including any complementary medicines)

___________________________________________________________________________________________________________
Target BP: Target lipid profile:
18. Had the patient had their blood pressure measured (measure BP every (measure lipids at least
by their GP within the last 34 months? annually if treated)
SA

34 months)
yes no not determined unknown < 125/75 mmHg total cholesterol: < 4.0 mmol/L
if proteinuria > 1 g/day LDL-cholesterol: < 2.5 mmol/L
19. Had the patient had their lipid levels measured
M

HDL-cholesterol: > 1.0 mmol/L

by their GP within the last 12 months? < 130/80 or 130/85 mmHg
triglycerides: < 1.5 mmol/L
PL

yes no not determined unknown

Counselling encounter
E

20. What written material was supplied to support verbal counselling:

Empower patients to understand their diabetes management
none patient information leaflets Provide relevant patient information leaflets to enhance verbal
CMI on antidiabetic agent(s) Pharmacy Self Care Card communication between the patient and the pharmacist, GP, practice
nurse and/or diabetes educator.
CMI for other medicines referral to website for information
patient medication list other ______________________

21. Approximate time for counselling on diabetes management

at this episode of care:
no counselling given 610 minutes
< 2 minutes > 10 minutes
25 minutes

Summary of planned actions

22. Mark any further actions to be implemented for this patient:

Consider recording specific details of further actions
Record on Couselling checklist

check adherence at next episode of care in patient profile on computer for future reference
contact carer/relative/support person
advice on specific lifestyle issues Other planned actions:

contact prescriber directly to discuss management _________________________________________________________________________________________________________________

refer to prescriber for review
_________________________________________________________________________________________________________________
refer to diabetes educator/practice nurse
_________________________________________________________________________________________________________________
refer to dietician
refer to other healthcare professional for lifestyle advice _________________________________________________________________________________________________________________

refer to GP for HMR/RMMR _________________________________________________________________________________________________________________

other _____________________________________________________________________________________________
NPSA0785
OKA6237 NPS PPR Pharm Enrol Form v2.qxd:PPA 12/6/08 1:41 PM Page 1

Pharmacy practice review

a counselling and action resource

Enhancing patient care in type 2 diabetes

Counselling patients with diabetes aims to improve the management of

their diabetes, their medicines and the risk associated with non-adherence.
Lifestyle changes and regular monitoring are also important to maintain
tight blood glucose control.

This activity will assist you to:

Assess and encourage adherence to management
Educate patients on the importance of regular
monitoring and achievement of blood glucose control
Reflect on priorities for and individualise counselling
Discuss progression of antidiabetic treatment
Provide quality care in pharmacy practice
Self-assess abilities and practice against standards.
This program is recognised by the:
Pharmaceutical Society of Australia (PSA) CPD&PI Program
for 8 credit points
Society of Hospital Pharmacists of Australia (SHPA) CPD Program
for 4 hours as a group 2 activity
Australian Association of Consultant Pharmacists (AACP) as
a group 2 activity for members who are accredited pharmacists
Pharmacy Board of South Australia for up to 8 ENRICH credits.

To order your free pharmacy practice review Your review must be completed and returned by:
Friday 24 October 2008 to receive feedback in February 2009.
Fax (02) 9283 2028 OR Post to:
Locked Bag 4888 For more information contact
Strawberry Hills NSW 2012 Sheena ORiordan or Michelle Koo
phone (02) 8217 8700, email info@nps.org.au
To see a sample review form before enrolling, visit
www.nps.org.au/healthpro

Enrolment
Your details: Please use BLOCK LETTERS

Title Mr Mrs Miss Ms Dr

Family name

Given name

Postal address

Town or Suburb

State or Territory Postcode Phone no.

PSA No required for CPD & PI points

I would be interested in participating in development

Registered pharmacist: of NPS pharmacy practice reviews and other activities.

Intern pharmacist
NPS adheres to the National Privacy Principles contained in the Privacy Act 1988 (Cwth). All personal information collected by NPS will be used only for mailing
of NPS materials relating to this activity and/or evaluation purposes.

NPS is an independent, non-profit organisation for Quality Use of Medicines,

funded by the Australian Government Department of Health and Ageing.
ABN 61 082 034 393 l Level 7/418A Elizabeth Street Surry Hills NSW 2010 l PO Box 1147 Strawberry Hills NSW 2012
Phone: 02 8217 8700 l Fax: 02 9283 2028 l email: info@nps.org.au l web: www.nps.org.au
NPSF0827
OKA6237 NPS PPR Pharm Enrol Form v2.qxd:PPA 12/6/08 1:41 PM Page 2

Pharmacy practice review

a counselling and action resource

Enhancing patient care in type 2 diabetes

This resource includes:

Pharmacy practice review: a counselling and action resource
Enhancing patient care in type 2 diabetes

How are you managing? Recognised by the:

Patients using an antidiabetic agent(s) with
a diagnosis of type 2 diabetes, confirmed
by the patient or their agent.
Pharmaceutical Society of Australia (PSA) CPD&PI Program for 8 credit points
Society of Hospital Pharmacists of Australia (SHPA) CPD Program for 4 hours as a group 2 activity
Australian Association of Consultant Pharmacists (AACP) as a group 2 activity for members who
are accredited pharmacists
Pharmacy Board of South Australia for up to 8 ENRICH credits.

Best practice in diabetes management

This activity will assist you to: understand and provide advice to patients on the medicines
determine and encourage adherence to antidiabetic management of diabetes and the progression to insulin
medications and ongoing lifestyle modifications to encourage patients to speak to their GP about their
prevent the long-term complications and improve diabetes management
management of diabetes identify patients who may benefit from
discuss importance of regular monitoring of HbA1c a Home Medicines Review
and reinforce recommendations of the annual cycle demonstrate provision of quality care
of care for diabetes
self-assess your abilities and practice against
reflect on priorities for patient counselling standards relevant to your role to determine

A simple-to-follow summary of current guidelines and practice standards.

and identify counselling points training/development needs.

1. Use best practice

standards and
guidelines

Assess and encourage adherence Do I routinely check adherence to medicine(s)?

5. Monitor progress
4. Review and reflect
to management
Routinely check adherence to medicines Do I encourage lifestyle modifications on an
and ongoing lifestyle issues
Educate patients on the
importance of regular monitoring and the importance of controlling blood glucose levels?
Promote the importance of regular Do I discuss with patients the importance of keeping
monitoring and achievement of
blood glucose control
Individualise counselling
Gather information and check
medication records to prioritise
patients
Discuss progression of
antidiabetic treatment
Explain the progression of
treatment to insulin therapy
Provide quality care
in pharmacy practice
What do I do to encourage adherence to medicines?
ongoing basis?
2. Review current
Do my patients understand the meaning of HbA1c
practice
a record of their clinical measurements?
Do I know the recommendations of the annual cycle
of care for diabetes?
Am I gathering enough information to tailor
counselling to the individual?
Do I ensure the patient understands what
they can do to help manage their diabetes?
Are the counselling and additional support
materials I provide to patients adequate?
Do I understand the treatment options for diabetes?
Can I explain the progression to insulin therapy?
Do I ensure each patient understands their diabetes 3. Consider implementing
medication management?
changes to pharmacy
Am I offering consumer medicines information (CMI)
as required by guidelines? practice
Have I identified patients who would benefit
from a Home Medicines Review?
Do I refer patients to the GP for a review of their
diabetes to facilitate the annual cycle of care?

Guide

Patient
Information Patient
Leaflet Information
Managing your diabetes your goals Leaflet
Managing your diabetes your lifestyle
You can control your diabetes by maintaining blood glucose levels, blood pressure and cholesterol
levels that are as close to normal as possible. Managing your diabetes also includes feet, urine, eye
and dental checks. By regular checking on these you can slow or prevent further complications
Simple lifestyle changes can help you control your diabetes and improve your blood glucose,
including heart disease, kidney disease, blindness, nerve damage and gum disease.
blood pressure, blood fat levels and help protect your eyes, feet and kidneys from disease.

Specially designed patient information leaflets to enhance your counselling WhenStop

Blood glucose levels (BGL) smoking
blood pressure is taken it is measured Physical activity
in millimeters of diabetes
If you have mercury and
(mmHg).
smoke, The reading
the risk of heart Exercise is vital in maintaining a
Regularly testing your own blood glucose levels
is recorded asstroke
disease, two numbers.
and the risk of losing limbs is healthy lifestyle. By becoming
can let you know about your bodys response to
increased.
For someone If you
with stop smoking,
diabetes, your
the target is risk reduces.
usually more active you can improve
things like medications, food, exercise and your
less than 130/80 (stated as 130 over 80). your general health,
general health. Where do I go to quit? quality of life and
Your doctor, diabetes educator, practice nurse or Your pharmacist
Cholesterol or doctor
(blood fats can give you support
or lipids) diabetes management.
specialist will help you decide how many tests are and refer you to other places to help you.
This is a type of fat in the blood. Cholesterol Aim for at least
needed, when to test your blood and the levels
Theare
problems Quitline
common provides counselling
in people with diabetes 30 minutes of
to aim for.
and too over
muchthefat
phone.
increases the risk of heart moderate-intensity

encounters. These leaflets can be reordered by participating pharmacists for

The target range is usually around 4 to 8 mmol/L. physical activity on
diseaseThe
andnumber
stroke. is 13 78 48. You can ring
this number at any time. most days of the
HbA1c (Glycosylated haemoglobin) Your target total cholesterol level is less week and resistance
than 4 mmol/L. training 2 to 3 times
This test shows the average of your blood glucose Healthy eating
There are two types of cholesterol low-density a week. You should notice your breathing and
level (BGL) over the past 1012 weeks. It does not
Healthy(LDL's)
lipoproteins eatingbad
can help control and
cholesterol yourhigh-
blood heart rate speeding up and perhaps a light sweat,
show the highs and lows but gives an overall
pressure,
density cholesterol
lipoproteins level
(HDL's) andcholesterol.
good blood glucose however you should still be able to talk. Try
picture of your blood glucose management.
level by preventing you from being overweight walking or gardening. Some people enjoy taking
High blood glucose levels contribute to the LDL-cholesterol can narrow
or having fatty depositsorinblock
your your
heart.blood a class in strength-based training, dancing, water
development of long-term complications vessels. Keeping your LDL low helps protect aerobics or Tai Chi. You can add up your activity:
of diabetes. Everyone, including people with diabetes can
your heart. three 10 minute sessions is the same as one
benefit from eating healthy foods. There is no 30 minute session.
It is best have your HBA1c level retested Your target LDL level is less than 2.5 mmol/L.
need for separate meals or a special diet but if you

ongoing use.
at least every 6 months are overweight
HDL-cholesterol helpssmaller
removemeals are from
deposits recommended.
your Stop exercising if you experience shakiness,
The target level is around 7% or lower. blood vessels and stops them getting blocked. tingling lips, hunger, weakness, palpitations, chest
pain, light headedness or difficulty breathing.
Your Most
targetimportantly
HDL level is 1enjoy a or
mmol/L wide variety
above.
Blood pressure (BP) of nutritious foods: Be sure to check with your doctor before starting
Triglycerides are another type of fat in your blood.
This is the measurement of the pressure at which Eat plenty of vegetables, legumes and fruit any new physical activity program.
your heart pumps blood around the body. Your target triglyceride daily
(Recommended level amount
is less than
for1.5 mmol/L.
adults
= 5toserves
It is best vegetables
have your + 2 serves
cholesterol levelsfruit. A serve
tested at Moderate alcohol consumption
High blood pressure can increase the risk of heart
of vegetables
least every 12 months.is equivalent
Cholesteroltolevels
1/2 cupcancooked
be
disease, stroke and kidney disease. Alcohol increases your likelihood of being
improvedvegetables e.g. broccoli,
with lifestyle changescarrot,
which stir-fry or
may reduce overweight and developing heart disease. It
It is best to have your blood pressure checked mixed
your need forvegetables
medication. or 1 cup of salad)
can increase your blood glucose levels. Most
regularly (at least every three months). It can Eat plenty of cereals (including breads, rice, people with diabetes can enjoy a moderate
be treated with medicines if necessary. pasta and noodles), preferably wholegrain amount of alcohol.
Include lean meat, fish and/or poultry, cut In general, the maximum amount of alcohol
the visible fat off your meat recommended for persons with diabetes is
Include milks, yoghurts, cheeses (moderate 2 standard drinks per day for men or women.
amounts) and/or alternatives. Reduced fat It is a good idea to have some alcohol-free days
varieties should be chosen where possible during the week.
Drink plenty of water
Limit takeaway foods and fatty and sugary
foods like sausages and cakes.
Please turn over

Please turn over

Enhancing patient care

in type 2 diabetes
Use a black biro to mark a cross (X) in the box beside your NPS office use only
response. If you make a mistake, use white correction fluid.
Do not complete this form while talking to the patient.
Complete as soon as possible after the episode of care.

Episode of care and antidiabetic medicines

1. Who was involved in this episode of care? the patient relative/carer/support person
AND community pharmacist accredited pharmacist hospital pharmacist intern pharmacist
2. Age of patient: 50 years > 50 years
3. Current antidiabetic agent(s) used (mark all that apply): 5. Indicate what verbal counselling you provided
at this episode of care (mark all that apply):
acarbose repaglinide

Mark these on Counselling checklist

purpose of antidiabetic medicines
glibenclamide rosiglitazone
Ensure understanding of importance of diabetes control
gliclazide insulin to prevent long-term complications.
glimepiride Fixed-dose how to take/use antidiabetic medicines
combination products Provide details on dose, timing and special instructions

Quick and easy-to-complete forms to review current practice for

glipizide
metformin/glibenclamide to optimise adherence.
metformin
metformin/rosiglitazone possible adverse effects of medicines
pioglitazone
Discuss potential for and how to manage adverse effects
4. Was the presenting prescription for antidiabetic agent(s): of antidiabetic medicine(s).
Thiazolidinediones: may increase risk of heart failure,
the first ever antidiabetic medicine used
myocardial ischaemia and fractures (see Guide page 2).
ongoing therapy
response to therapy
a change or addition to ongoing therapy Ensure understanding of how response to antidiabetic treatment
not determined is assessed and discuss strategies to manage hypoglycaemia.

Controlling blood glucose levels

6. How did you assess adherence with antidiabetic medicines?

10 patients with type 2 diabetes.

Regularly check dispensing records to monitor adherence.
not applicable (first dispensing) dose administration aid returns
Discuss with patient we all forget to take our medicine(s)
dispensing of repeat prescriptions not assessed sometimes. How many doses have you forgotten in the last week?
open questioning other ___________________
12. Indicate what verbal counselling you provided
7. Was the patient using any other medicines that may at this episode of care (mark all that apply):
affect control of blood glucose? (see Guide, page 6) importance of adherence to medicines

Mark these on Counselling checklist

yes no not determined Consider strategies to assist adherence. (see Guide, page 3)

8. Did the patient self-monitor blood glucose levels? potential interactions with other medicines.
Remind patient of need to check with doctor or pharmacist
yes no not determined
for potential drug interactions.
Were levels recorded? how to manage hypoglycaemia (see Guide, page 4)
yes no not determined Remind patient of symptoms and use of
quick acting carbohydrate.
9. Had the patient had their HbA1c measured
by their GP within the last 6 months? need for ongoing monitoring
Discuss meaning of HbA1c and blood glucose levels.
yes no not determined unknown
Self-monitoring needs to be recorded for GP to review.
10. Did the patient know their HbA1c measurement? Stress importance of regular checking and achievement of targets.
yes no not determined importance of ongoing lifestyle modification
Early and continued lifestyle changes reduce overall
11. Had the patient had their weight or waist circumference
cardiovascular risk and disease progression.
measured by their GP within the last 34 months?
yes no not determined unknown 13. What ongoing lifestyle advice has been provided?

none minimise salt intake

Target blood glucose levels: 46 mmol/L (fasting)
Encourage self-monitoring: frequency should be individualised quit smoking reduce weight
to reflect therapeutic aims. healthy eating reduce saturated fat
Target HbA1c levels: 7% (measure HbA1c at least 6 monthly)
high-fibre/low reduce sugar intake
Needs to be regularly measured and is assessed when considering
glycaemic index diet regular moderate exercise
initiation of insulin.
Target BMI: < 25 kg/m2 minimise alcohol intake
other ___________________
Target waist circumference: < 94 cm (male), < 80 cm (female)
Please turn over to continue

A checklist and action plan to document what counselling you provided,

identify ongoing counselling required and help you plan any necessary
follow-up for your individual patients.

Review your practice

Pharmacy practice review: Enhancing patient care in type 2 diabetes

Completing this Pharmacy practice review: After completing the 10 forms, review your current practice and identify your training/development needs.

A one-page summary for you to clearly review your practice against

Complete the details below and keep for future reference.

Review your current

pharmacy practice Complete your own training/development plan

Yes Usually No My training/development plan How I will implement this plan Due date

If you tick () a shaded box

below complete your plan

Do I routinely assess and effectively encourage patients

adherence with their antidiabetic medicines and ongoing
lifestyle modifications?

pharmacist competencies and standards, and identify your future training

(Competency units 3.1, 4.2, 4.3; Standard 7.2)1,2

Do I promote the importance of regular monitoring

and achievement of blood glucose control?
(Competency units 3.1, 3.2, 6.3; Standard 2.5)1,2

Do I individualise counselling by exploring patients knowledge

and understanding of their antidiabetic medicines and blood
glucose control?
(Competency units 3.2, 4.2, 6.2, 8.1; Standards 1.6, 7.2)1,2

Is my knowledge of diabetes and progression of antidiabetic

treatment evidence based and up to date?

and development needs.

(Competency units 1.3, 2.1; Standard 7.7)1,2

Do I refer confidently to other healthcare professional

when appropriate?
(Competency units 1.2, 2.3, 6.1, 8.4; Standard 1.9)1,2

Do I provide written information to supplement oral

counselling in a timely manner when appropriate
for patients with diabetes?
(Competency units 1.2, 7.3; Standards 2.8, 7.4, 15.4)1,2

Other issues I identified:

1. Pharmaceutical Society of Australia (PSA). Competency standards for pharmacists in Australia 2003. Canberra: PSA, 2003. NPSA0785
2. PSA. Professional practice standards, version 3, December 2005. Canberra: PSA, 2006.

Report
An individualised feedback report with aggregate results of all pharmacist
participants to enable you to review your practice against your peers.
Your results

Comments from pharmacists who have

already completed these activities:
It helps me establish
priorities when counselling
patients and reminds me to
They (these activities) help us also ask lifestyle questions
to optimise our counselling and
achieve the best results for each
of our customers I would definitely
recommend (these activities)
to other pharmacists