Pharmacists are the frontline warriors in managing diabetes medicines, writes Louis Roller
- One person develops diabetes every five minutes.
- Around 1.5 million Australians have diabetes. This includes all types of diagnosed diabetes (1.2 million known and registered) as well as silent, undiagnosed type 2 diabetes (500,000 estimated).
- More than 100,000 Australians have developed diabetes in the past year.
- For every person diagnosed with diabetes there is usually a family member or carer who also ‘lives with diabetes’ every day in a support role. This equates to about 2.4 million Australians being affected.
Type 2 diabetes affects 85–90% of all people with diabetes. It usually occurs in adults but younger people and even children are now getting this lifestyle condition.
Complications are the major cause of associated morbidity and mortality; the major aim of diabetes management is to prevent complications.
For people with type 2 diabetes healthy eating and regular physical activity is important.
Diabetes is a progressive condition. Over time many people with Type 2 diabetes will need to commence oral hypoglycaemic medication(s) and possibly insulin to stay healthy and prevent complications.
Signs and Symptoms of Type 2 diabetes
Many people have no symptoms at all, while other signs can go unnoticed and mistaken as part of “getting older”.
Common symptoms can include: increased thirst, frequent urination, feeling tired and lethargic, always feeling hungry, cuts that heal slowly, itching, skin infections, blurred vision, mood swings, headaches, feeling dizzy and leg cramps.
If an individual is experiencing any of these symptoms, has a family history of diabetes, has taken the AusDrisk test and scored a high risk or have any concerns, it is important to seek medical help as soon as possible, as the earlier diabetes is diagnosed, the better.
All pharmacists are encouraged to take the AusDrisk test themselves, as well as encouraging patients to do the same.
The goals of treatment are to help prevent or delay the onset of diabetes and involve adopting healthy lifestyle changes and increasing physical activity to assist with weight management.
People with pre-diabetes are also at increased risk of heart disease, so controlling blood pressure and blood cholesterol is also important.
There are now a large number of medications to treat Type 2 diabetes. The various groups act by different mechanisms and often two or more medications might be used in combination. Pharmacists are the front-line warriors in preventing drug interactions and identifying any reported side effects.
Pharmacists should also be on the lookout for symptom of hypoglycaemia and warn their patients to look out for:
- nervousness or anxiety;
- sweating, chills and clamminess;
- irritability or impatience;
- confusion, including delirium;
- rapid/fast heartbeat;
- lightheadedness or dizziness; and/or
- hunger and nausea.
Pharmacists should be aware of and encourage all people with type 2 diabetes to approach or reach the following goals:
Advise eating according to Australian Dietary Guidelines with attention to quantity and type of food.
If concerns are held regarding cardiovascular disease, advise individual dietary review.
Body Mass Index (BMI) (kg/m2)
Therapeutic goal is 5–10% loss for people overweight or obese with type 2 diabetes.
With BMI >35 and comorbidities or BMI >40, greater weight loss measures should be considered. Note that BMI is a difficult parameter to standardise between different population groups.
At least 30 minutes of moderate physical activity on most if not all days of the week (total ≥150 activity minutes/week).
0 per day
Advise ≤2 standard drinks (20g ethanol) for men and women
Blood Glucose Level (BGL)
6–8 mmol/L fasting and 8–10 mmol/L postprandial.
Ongoing self-monitoring of blood glucose is recommended for people with diabetes using insulin, with hyperglycaemia arising from illness, with haemoglobinopathies, pregnancy or other conditions where data on glycaemic patterns is required.
Routine self-monitoring of blood glucose in low-risk patients who are using oral glucose-lowering drugs (with the exception of sulphonylureas) is not recommended.
Glycated haemaglobin (HbA-1c)
Needs individualisation according to patient circumstances.
Generally: • ≤53 mmol/mol (range 48–58) • ≤7% (range 6.5–7.5). Allowing for normal variation in test accuracy, HbA1c results which range between 6.5 and 7.5% 48 and 58 mmol/mol) would reflect this goal.
Cholesterol total (mmol/L) < 4.0
HDL-C (mmol/L) ≥1.0
LDL-C (mmol/L) < 2.0
Non-HDL-C(mmol/L) < 2.5
Initiation of pharmacotherapy is dependent on the assessment absolute cardiovascular risk. Refer to the Australian Absolute Cardiovascular Risk Calculator http://www.cvdcheck.org.au/.
This requires using mutiple risk factors, which is considered more accurate than the use of individual parameters.
Once therapy is initiated the specified targets apply; however, these targets should be used as a guide to treatment and not as a mandatory target.
Blood pressure (BP)
≤ 140/90 mmHg
Lower BP targets may be considered for younger people and for secondary prevention in those at high risk of stroke, as long as the burden does not increase risk.
The target BP for people with diabetes and albuminuria/proteinuria remains < 130/80 mmHg. As always, treatment targets should be individualised and monitored for side effects from medications used to lower BP.
Urinary albumin excretion
Timed overnight collection (mcg/min): <20
Spot collection (mg/L): < 20 mg/l
Urinary albumin-to-creatinine ratio (UACR)
· Women (mg/mmol): <3.5
· Men (mg/mmol): < 2.5
Consider immunisation against influenza and pneumococcal disease, and the dTPA (diphtheria-tetanus-Acellular pertussis) vaccine.
Consider the shingles (Herpes zoster) vaccine, which has been approved to be placed on the National Immunisation Program (NIP), provided free of charge since 1 November 2016 to people aged 70 years.
Associate Professor Louis Roller, from the Faculty of Pharmacy and Pharmaceutical Sciences Monash University, was the 2014 recipient of the PSA Lifetime Achievement Award.