Diabetes Patients and MURs

Chris Roome
Interface Development
Pharmacist, RD&E
Diabetes a recap
Type 1
Insulin dependent due to failure of insulin secretion
Typically younger patients
Accounts for around 10% of prevalent cases
Type 2
Non insulin dependent (although some eventually
require insulin). Primarily due to resistance to action
of insulin
Typically older, overweight patients
Accounts for around 90% of prevalent cases
Diabetes definition
Diagnosed by abnormal plasma glucose
measures:
Symptomatic plus fasting glucose >7 mmol/l
random glucose >11.1 on one occasion.
Or
No symptoms plus above measurements
recorded on two occasions

But diabetes is not just about
plasma glucose levels
When conducting an MUR on a diabetic
patient think:
Blood sugar
Cardiovascular risk
Complications of diabetes
Management of hyperglycaemia-
Insulin
Insulins- now many types and a multitude of
devices giving rise to potential confusion.
Check the patient uses these appropriately
Check for recent changes in medication especially
with switches to the newer analogues
Have there been any problems since the change eg hypos,
and how have these been managed?
Check which health professional usually looks after
the diabetes eg GP, practice nurse, local specialist
centre as this may affect the communication
necessary as a result of the MUR
Insulins recap of types

Traditional Insulins

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

traditional insulins contd
Intermediate acting eg insulatard
Onset of action 1-2 hours, peak 4-12 hrs,
duration up to 24 hours.
Used in type 1 diabetes as part of the basal-
bolus regimen or in self mix bd regimens.
Used in type 2 diabetes (+OHDs) as a night
time dose.
Long acting traditional insulins such as
insulin zinc suspension are now rarely
used
Newer insulin analogues
Very short acting (eg lispro, aspart,
glulisine)
Very fast onset so may be given immediately
before or straight after a meal.
Shorter duration of action that soluble insulin
so possibly less problems with hypos.
Long acting analogues (glargine, detemir)
Onset 2-4 hours duration up to 24 hours, but
some patients require bd dosing
Disposal of sharps
Check the patient knows how to and
actually does dispose of the needles and
syringes appropriately. (sharps containers
and route of disposal)
Type 2 diabetes-usual
management plan
First line management in type 2 diabetes
is diet
If this fails all patients except the
underweight will generally commence
metformin
If HbA1c not sufficiently controlled add a
sulphonylurea
If still not controlled consider glitazones or
insulin
Metformin
Doesnt stimulate insulin production so doesnt cause
hypos
Good evidence for reduced risk of diabetic complications
(MI etc)
Commonly causes GI upset. Usual to start with low dose
(500mg od) and increase slowly. Taken after food to
minimise GI irritation
If compliance is an issue due to GI upset check patient is
taking after food. If recently started or dose increase the
patient may be able to tolerate a lower dose with
possible later increase which would be more beneficial
than stopping. (might try 250mg alt die to start)
Check compliance with regimen (often tds and big
tablets especially the 850mg!)

Sulphonylureas
Act by increasing insulin secretion
May produce hypoglycaemia (which can
be severe and life threatening). Patients
should carry a card/tag. Long acting
agents are more likely to cause problems
especially in the elderly.
Usually quite well tolerated but check
patient is taking them as prescribed (many
are BD dosing)
Glitazones
Act by reducing insulin resistance.
Mechanism of action means they may take up to
2-3 months to exert their effect. Might need to
encourage a patient to continue if they want to
cease therapy due to an apparent lack of
benefit.
May cause weight gain
Potential serious s/e is development of heart
failure- beware reports of new onset fluid
retention, breathlessness etc.
Monitoring blood glucose
The PCT spends more on prescribed testing
strips than on oral hypoglycaemic drugs.
The PCT has agreed a testing plan with the local
consultants and patient groups.
The principal is only to test if the result will lead
to a change in therapy/dose. Therefore the
recommendations are different dependant upon
use of insulin or not.
Blood Glucose testing for patients
on insulin
If on a regimen where the dose of insulin is
adjusted in relation to meals and lifestyle eg
basal-bolus then testing up to 4 times a day may
be indicated (pre meals and bed time). The
patient will have been instructed how to adjust
dose in response to the readings
If a type 2 diabetic on insulin testing once a day
at different times of day including first thing in
the morning will build up a profile which the
healthcare professional can use to advise on
dose adjustment.
Blood glucose testing for patients
on oral hypoglycaemic drugs
Unnecessary if on metformin
If on sulphonylureas (or meglitinides)
where there is a risk of hypos testing up to
3 times a week is recommended.
Other issues related to blood
glucose
Patients at risk of hypoglycaemia should
carry or have access to medication for a
hypo- a source of dextrose- could be
tablets, medication (eg.hypostop) or food.
Patients relatives may need to administer
glucagon. Need to check expiry dates if
rarely used. Need to know what to do in an
emergency.
Medication for cardiovascular risks
of diabetes
1.Hypertension
Control of blood pressure is essential to
prevent long term complications.
NICE guidance is to treat in type 1
diabetes if BP>135/85 (or 130/80 if kidney
damage) using thiazides as first line. Use
ACEi if evidence of kidney damage,
including microalbumiuria.
Management of BP
In type 2 diabetes NICE guidance is to treat if
BP>160/80 but
Treat if BP>140/80 if history of CVD or >15% 10-
year risk
Treat above patients with either ACEi or thiazide
as first line
If >140/80 and with evidence of kidney damage
treat with ACEi as first line and treat to target of
135/75
Where an ACEi is indicated but not tolerated an AT2 antagonist may be used

MUR opportunities with
antihypertensives
Diuretics
Check compliance. Treatment choice is low
dose bendroflumethiazide which should not
cause troublesome diuresis when taken om.
Higher doses offer little/no therapeutic benefit
but will increase side effects.
[also consider clinical issues of metabolic
disturbance- low K, low Na, glucose]
ACE Inhibitors
Check compliance- These are not as well
tolerated as might be expected see side effect
list in the BNF
ACE cough- widely recognised but avoid making
a knee jerk diagnosis and recommending a
switch. Most of the evidence of benefit of
blocking renin angiotensin system is with these.
Cough could be viral, asthma, CHF or other
pathology. Look for temporal association and if
possible organise a re challenge.
Check K intake (no salt substitutes etc)
Medication for cardiovascular risks
of diabetes
2. Lipids
In type 1 diabetes NICE recommend statins for
those with kidney damage, >2 features of the
metabolic syndrome, age>35, FH, high risk
ethnic group and severe lipid abnormalities.
In type 2 diabetes NICE recommend statins if
TC>5 with >15% 10-yr CVD risk (consider a
statin at lower risks).
Fibrates may also be used if Triglycerides are
raised
Statins
On theoretical grounds simvastatin should be
taken at night (the cholesterol fairy!) but in
practice take at a time the patient will reliably
remember it.
Main serious side effects are liver (not obvious)
and myopathy (pt may report muscle tenderness
etc- should not be ignored-refer back to GP).
Increased risk of myopathy when used in
combination with a fibrate.
Other non serious side effects common and may
limit compliance -check

Statins
Simvastatin and atorvastatin are metabolised via c p450
giving rise to a number of important interactions
increasing toxicity
Avoid grapefruit juice
Avoid simvastatin with potent CYP3A4 inhibitors such as
macrolides and azoles
Max dose 10mg with ciclosporin, gemfibrozil, niacin
Max dose 20mg with amiodarone and verapamil
Max dose 40mg with diltiazem
Atorvastatin interacts with same range and advice is to
use with caution
Medication for cardiovascular risks
of diabetes
2. Antiplatelets
In type 1 diabetes NICE recommend
aspirin 75mg for the same patient group
as statins.
In type 2 diabetes NICE recommend
antiplatelets for secondary prevention and
also in those with a 10-year CHD risk
>15% if BP is controlled <145 systolic
Aspirin

very important intervention in secondary prevention of
CVD
Usual to use dispersible (historically cheaper)
No clinical advantage to EC preps -if patient finds
dispersible unpalatable use the ordinary tabs
Concurrent use of aspirin with a COX-2 inhibitor
removes the small reduced risk of GI complications.
Need a PPI (probably with a traditional NSAID given
adverse CV effects of COX 2 inhibitors) BUT both
COX2 inhibitors and NSAIDS are best avoided in pts
with renal disease unless no other alternative.
Medications for other complications
of diabetes
Neuropathic pain
Amitriptyline- started low increased gradually
well known and troublesome adverse effects check for
compliance, knowledge of use and benefit
Gabapentin-gradually increasing titration
schedule. Side effects of dizzyness may be
common
Antiepileptics- carbamazepine, phenytoin,
sodium valproate- check for knowledge of use
and compliance with regimen. Also beware
drug interactions with these!
Other complications of diabetes
which may result in medication
Gastroparesis- prokinetics or erythromycin
Erectile dysfunction
Remember diabetes isnt just about
blood sugar control
When conducting an MUR on a diabetic
patient think:
Blood sugar
Cardiovascular risk
Complications of diabetes