Clinical tips: Diabetes


the word diabetes is written on a chalkboard

Pharmacists are the front-line warriors in preventing drug interactions when it comes to diabetes, writes Louis Roller

Facts

  • 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.

People are at a higher risk of getting type 2 diabetes if they:

  • have a family history of diabetes
  • are older (over 55 years of age )- risk increases as we age
  • are over 45 years of age and are overweight
  • are over 45 years of age and have high blood pressure
  • are over 35 years of age and are from an Aboriginal or Torres Strait Islander background
  • are over 35 years of age and are from Pacific Island, Indian subcontinent or Chinese cultural background
  • are a woman who has given birth to a child over 4.5kgs, or had gestational diabetes when pregnant, or had Polycystic Ovarian Syndrome.

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’.

Symptoms include:

  • being excessively thirsty;
  • passing more urine;
  • feeling tired and lethargic;
  • always feeling hungry;
  • having cuts that heal slowly;
  • itching, skin infections;
  • blurred vision;
  • gradually putting on weight;
  • 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 Australian Type 2 Diabetes Risk Assessment Tool (AusDrisk) test and has a high score, 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 lipids 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 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
  • hunger and nausea.

Pharmacists should encourage all people with Type 2 diabetes to approach following goals:

Diet

Advise eating according to Australian dietary guidelines, with attention to quantity and type of food If concerns are held regarding cardiovascular disease (CVD) risk, advise individual dietary review

Body mass index (BMI)

Therapeutic goal is 5–10% weight loss for people who are overweight or obese with type 2 diabetes Those with BMI >35 kg/m2 and comorbidities, or BMI >40 kg/m2 , greater weight loss measures should be considered Note that BMI is a difficult parameter to standardise between different population groups

Physical activity

At least 30 minutes of moderate physical activity on most if not all days of the week (total ≥150 minutes/week)

Cigarette consumption

Nil

Alcohol consumption

Advise ≤2 standard drinks (20 g) per day for men and women

Blood glucose level (BGL)

Advise 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, people using sulphonylureas or other medicines that may cause hypoglycaemia, 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 haemoglobin (HbA1c)

Needs individualisation according to patient circumstances. Generally: ≤53 mmol/mol (48–58 mmol/mol), ≤7% (6.5–7.5%) Allowing for normal variation in test accuracy, HbA1c results that range between 6.5% and 7.5% (48 and 58 mmol/mol) would reflect this goal

Total cholesterol <4.0 mmol/L

High-density lipoproteincholesterol (HDL-C) ≥1.0 mmol/L

Low-density lipoprotein

cholesterol (LDL-C) <2.0 mmol/L

Non–HDL-C <2.5 mmol/L

Triglycerides <2.0 mmol/L

Initiation of pharmacotherapy is dependent on the assessment of absolute CVD risk (refer to the Australian absolute CVD risk calculator at www.cvdcheck.org.au). This requires using multiple 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 ≤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 treatment burden does not increase risk The target BP for people with diabetes and albuminuria/proteinuria remains

Urine albumin excretion

Urine albumin-to-creatinine ratio (UACR):

• women: < 3.5mg/mmol

Men:  <2.5 mg/mmol

Timed overnight collection : < 20 mcg/min

Spot collection: < 20 mg/L

Vaccination

Consider immunisation against influenza and pneumococcus

 

https://www.racgp.org.au/FSDEDEV/media/documents/Clinical%20Resources/Guidelines/Diabetes/Type-2-diabetes-Goals-for-optimum-management.pdf

http://www.health.gov.au/internet/main/publishing.nsf/Content/diabetesRiskAssessmentTool

https://www.diabetesaustralia.com.au/type-2-diabetes

Associate Professor Louis Roller, from the Faculty of Pharmacy and Pharmaceutical Sciences Monash University, was the 2014 recipient of the PSA Lifetime Achievement Award.

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