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cpd module
THE

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CONTINUING

PROFESSIONAL
DEVELOPMENT
PROGRAMME

This module is suitable for use by pharmacists as part of their continuing professional development cycle. Complete the record form on
page viii for inclusion in your CPD portfolio. Previous modules in the Pharmacy Magazine CPD Programme are available to download at
www.pm-modules.co.uk

CURRENT THINKING ON...

MODULE

177 THE MANAGEMENT OF

Welcome to the one hundred and seventy seventh module

in the Pharmacy Magazine Continuing Professional
Development Programme, which looks at the management
of type 2 diabetes. It is valid until June 2013.
Continuing professional development (CPD) is now a
mandatory requirement for pharmacists. Journal-based
educational programmes (unscheduled learning) are an
important means of keeping up-to-date with clinical
and professional developments and form a significant
element of your CPD. Completion of this module will
contribute to the nine pieces of CPD that must be
recorded a year.
Before reading the module, assess your learning
needs by answering the questions below. After reading
the module, complete the record form on page viii for
inclusion in your CPD portfolio. You can also test your
knowledge by answering the multiple choice questions.
A 3.75 marking charge applies to each module.

Self-assess your learning needs:

What are the signs and symptoms of diabetes,
and how is the condition diagnosed?
Describe the common concomitant conditions
and long-term consequences of diabetes
How are the treatment targets for diabetes
measured?
This module supports the following CPD
competences:
C1c, C2c, C4g and C5c.
More details on pvii

FOR THIS MODULE

TYPE 2 DIABETES
Contributing author: Alpana Mair MRPharmS, BSc, MSc, MCPP,
Warwick Diploma in Diabetes Care, Chair of the Pharmacy Diabetes
Strategy Group, Lothian
Introduction
Diabetes affects approximately 2.6 million
people in the UK1 but there is likely to be
at least half a million more people who are
unaware they have the condition. Community
pharmacists are in an ideal position to identify
these patients because they may present at the
pharmacy looking for OTC remedies to treat
symptoms of undiagnosed diabetes, such as
passing urine frequently (especially at night),
increased thirst, extreme tiredness, unexplained
weight loss and genital itchiness.
Prevalence of diabetes is not distributed
evenly across the population it increases
markedly with age and is associated with social
deprivation. However some of the most
significant differences are associated with
ethnicity. People from Afro-Caribbean communities are up to three times more likely

to develop type 2 diabetes than Caucasians,

while prevalence in people of South Asian ethnic
origin can be up to six times higher.
The NHS spends about five per cent of its total
budget and 10 per cent of its secondary care
budget on treating diabetes and its consequences.
The proportion of the NHS budget accounted
for by diabetes is forecast to double but perhaps
the greatest costs (financial and emotional) are
borne by the individuals with diabetes and
the communities in which they live. People with
diabetes spend 1.1m days a year in hospital and
500m of their own money on coping with
their condition. Social care costs alone are
believed to be around 230m. Medicines make
up a large part of expenditure and from 2002 to
2008 the cost of prescribing has increased by
93.2 per cent and the number of items prescribed
by 73.3 per cent2.

GOAL:

To consider the role pharmacy can play in preventing type 2 diabetes and
reducing the burden of diabetes on the individual and society.

OBJECTIVES:

After completing this module, you should be able to:

Discuss lifestyle changes that individuals can make to prevent or delay the onset
of type 2 diabetes
Identify how care is provided for people with diabetes in your locality and how you
can integrate service provision with other healthcare professionals.

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Pharmacy has a major role to play in helping
to reduce the burden of diabetes by participating
in the delivery of local services and assisting
people with diabetes to better manage their
condition.

Table 1: Features of type 1 and type 2 diabetes

Features of type 1 diabetes

Features of type 2 diabetes

Pancreatic beta cell dysfunction and absolute

insulin deficiency

Defective glucose metabolism, poor cellular uptake of

glucose due to lack of insulin or insulin resistance

Peak onset < 25 years

Peak onset > 30 years

What is diabetes?

Accounts for about 15% of patients

Accounts for about 85% of patients

The World Health Organization3 defines diabetes

mellitus as a metabolic disorder of multiple
aetiology characterised by chronic hyperglycaemia with disturbances of carbohydrate, fat
and protein metabolism, resulting from defects
in insulin secretion, insulin action or both3.
There are two main types of the disease:
Type 1 diabetes
Type 2 diabetes.

Underweight or normal body weight

Commonly overweight/obese

Acute onset of symptoms

(e.g. thirst, frequency of urination)

Gradual onset of symptoms

Susceptible to ketoacidosis

Not susceptible to ketoacidosis (ketosis can occur)

Strong genetic susceptibility

Family history often positive

Immune markers (e.g. raised islet autoantibodies)

are common

Immune markers are less frequent

This develops if the body is unable to produce

any insulin due to the destruction of beta cells in
the pancreas. Of the total number of people with
diabetes, approximately 15 per cent have type 1
diabetes. It is classically a disease of the young.
In a survey of young patients attending a diabetic clinic, 97 per cent were diagnosed as having
type 1 diabetes.

diabetes that develops typically before the age of

25 years and affects one to two per cent of
those diagnosed with diabetes.
It is now known that the boundaries between
type 1 and type 2 diabetes are not as firmly
established as was previously considered (see
Table 1).
As well as achieving blood glucose control,
the main aim of treatment is to prevent
complications, such as cardiovascular disease,
amputation, blindness, kidney failure and
neuropathy.

Type 2 diabetes

Case history no.1

Type 2 diabetes develops when insulin secretion

is inadequate or there is insulin resistance. The
body initially responds by increasing insulin
production but, as the beta cells of the pancreas
become exhausted, less is produced. This type
of diabetes accounts for approximately 85 per
cent of cases (adults and children) and is most
commonly seen in people over 40 years of
age, although it can occur at a younger age (25
years and over) in Asians and Afro-Caribbeans.
Research also shows that more children
some as young as seven years are now being
diagnosed with type 2 diabetes. Some cases are
due to obesity but others are due to maturity
onset diabetes of the young (MODY) a type of

Mrs M comes into your pharmacy. When she

measured her blood glucose levels at her friends
house, the result was 7.8mmol/L. She had
had a cup of tea and a cereal bar about an hour
before the test. Mrs M is of Asian origin. Her
mother has type 2 diabetes and she is worried that
she too might have diabetes. On questioning she
tells you she weighs 69kg and she is 1.5m tall.
What advice would you give her?

Type 1 diabetes

Gestational diabetes
Gestational diabetes is experienced in two to four per
cent of pregnancies4. Those at risk are older women,
those with a previous history of glucose intolerance or
babies that are large for gestational age. About two-thirds
will go on to develop diabetes in the next 20 years.
Maintaining weight within the normal levels through adult
life will reduce the risk.

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WHO diagnostic criteria for diabetes3

Once a patient has been identified as having
some of the symptoms of diabetes, a diagnosis
can be made depending on the test results (see
Diagnostic criteria for diabetes table). If the
patient does not have any of the symptoms,
then diagnosis should not be based on a single
measurement. HbA1c is not considered a suitable
diagnostic test for diabetes as it is specific but
lacks sensitivity.

Diagnostic criteria for diabetes3

Diabetes
Fasting venous plasma blood glucose
> 7.0mmol/L
OR
Two-hour venous plasma blood glucose
> 11.1mmol/L
after ingestion of 75g glucose (oral glucose tolerance test)
Impaired Glucose Tolerance (IGT)
Fasting venous plasma blood glucose
< 7.0mmol/L
AND
Two-hour venous plasma
> 7.8mmol/L < 11.1mmol/L
blood glucose after ingestion of 75g glucose (oral glucose
tolerance test)
Impaired Fasting Glucose (IFG)
Fasting venous plasma blood glucose
6.1-6.9mmol/L
AND
Two-hour venous plasma blood glucose
< 7.8mmol/L
after ingestion of 75g glucose (oral glucose tolerance test)

Waist measurement
One cause of insulin resistance is thought to
be the accumulation of surplus fat around the
abdomen. The genetic make-up of those prone
to insulin resistance causes fat to be stored
around the abdomen rather than as glycogen in
the skeletal muscle. This results in an apple
shape, with these individuals more prone to
heart disease than those who are pear shaped.
Reduction in waist measurement will help
improve blood glucose control and prevent
diabetic complications. Waist circumference
measurements should be as below:
94cm (37 inches) in white and black men
90cm (35 inches) in Asian men
80cm (31.5 inches) in white, black and Asian
women1.

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CHASSENET/SCIENCE PHOTO LIBRARY

Metabolic syndrome
This describes a series of risk factors that are
commonly found in type 2 diabetes. These
include:
Insulin resistance, glucose intolerance, hyperinsulinaemia
Central obesity
Hypertension, dyslipidaemia
Atherosclerosis
Increased levels of procoagulant factors, such
as plasminogen activator inhibitor-1 and
fibrinogen.

Body mass index

Body mass index (BMI) is a good indicator of
weight ranges. It is calculated by weight in kg
divided by height in m2. Weight classification is
slightly different for people of Asian origin and
the BMI measure can be inaccurate at times for
people who have a lot of lean muscle (e.g. rugby
players or weight lifters).
Going back to Mrs M (case study, previous
page), it is important to explain that proper tests
are needed to confirm diabetes and to find out
if she has any underlying symptoms. Fasting
plasma could be recommended but is complicated by the fact that she would need to fast
overnight and attend the surgery first thing in
the morning. If Mrs M has some symptoms of
diabetes, a single fasting plasma glucose test
above the threshold value would confirm a
diagnosis according to WHO standards. If Mrs
M has no symptoms of diabetes, two test results
would be needed to confirm the diagnosis.

Alcohol and diabetes

People with diabetes do not need to avoid alcohol but
should be aware of the effects that alcohol can have.
Although alcoholic drinks do contain carbohydrates,
alcohol actually causes a lowering of blood sugar
therefore drinking can lead to the development of
hypoglycaemia in people with type 1 diabetes and those
with type 2 diabetes who are taking certain types of oral
hypoglycaemics.
Alcohol tends to impair judgement and makes it more
difficult to recognise the onset of a hypoglycaemic event.
The symptoms of hypoglycaemia and drunkenness are
similar and other people may not realise the need to
provide assistance until unconsciousness sets in.
Hypoglycaemia can still develop some hours after
stopping drinking. People with diabetes are advised to:
Not drink on an empty stomach
Snack if they are out late
Check their blood glucose before they go to bed
Carry glucose tablets
Always carry identification that indicates they
have diabetes.

Close management of diabetes is essential to prevent complications like CVD

Currently Mrs Ms random values put her

below the threshold for diabetes but she might
be at risk of impaired glucose tolerance or
impaired fasting glucose risk factors for later
developing diabetes.
The 75g oral glucose tolerance test (OGTT) is
considered to be the gold standard for diagnosing the diabetes and pre-diabetes states.
Again, in the absence of symptoms, a test on
each of two different days would be required.
Mrs Ms BMI is 30.6 (in the obese range), so
she needs to be advised about measures she can
take to prevent diabetes developing in
particular, dieting, losing weight and exercising.
Physical activity is likely to be beneficial and at
this stage may the best option. Physical inactivity
is a major risk factor for the development of
type 2 diabetes, with active people having a
33-50 per cent lower risk compared with inactive
people. High-risk individuals in particular can
substantially reduce their chances of developing type 2 diabetes by becoming more active.

Treatment of diabetes
The main aim of treatment of both types of
diabetes is to achieve blood glucose, blood

Reflection exercise 1
Consider the people with diabetes that you see in your
pharmacy. How confident are you that they take their
medication as advised? Do they understand the benefits
and risks of the medicines they are taking? How might
you help them obtain greater efficacy from their
medication?

pressure and cholesterol levels as near to normal

as possible. This, together with a healthy lifestyle,
will help to improve wellbeing and protect
against long-term damage to the eyes, kidneys,
nerves, heart and major arteries.

Type 1 diabetes
Since type 1 diabetes results from a destruction
of pancreatic beta cells leading to an insulin
deficiency, treatment is always with insulin.
The Diabetes Control and Complications Trial5
provides evidence of a close association between
sustained glycaemic control and microvascular
and macrovascular complications with no
threshold effect, so that any decrease in HbA1c
is associated with a similar decline in relative
risk of complications. There is no HbA1c below
which complications are completely prevented.

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Reflection exercise 2
How are people with diabetes encouraged to establish
a healthier lifestyle with respect to smoking, diet and
activity, and psychological and peer support? How might
you create opportunities to encourage healthy lifestyles
for people with diabetes in your area?

osmotic diuresis. She can take paracetamol but

decongestants should be used with caution as
there is a risk of impairment of glucose control.

Types of insulin and practical tips

Patients with diabetes should be advised to rotate the site of their insulin injections

Diabetic ketoacidosis

Case history no. 2

Diabetic ketoacidosis (DKA) is a potentially

life-threatening complication of diabetes caused
by hyperglycaemia due to absolute insulin
shortage, which results in increased ketone
levels inducing metabolic ketoacidosis. This
often arises with new onset diabetes and can also
occur in those with intercurrent illness or poor
compliance with insulin therapy. DKA usually
presents as a medical emergency that requires
urgent hospital treatment.

Sally is a 25-year-old student with type 1 diabetes

who comes into the pharmacy looking for
something for a cold. She is off her food and
not using her insulin. She normally takes a cold
sachet containing paracetamol and a decongestant but wants something stronger to help her
recover quickly because she needs to revise.
As illness can stimulate increased glucose
secretion, Sally needs to increase her insulin and
fluid intake. Patients with type 1 diabetes may
need to test their blood glucose and ketones, but
the most important thing is not to stop using
insulin. If Sally is unable to eat because she is
vomiting, she must seek immediate medical help.
It is important that she does not get dehydrated as high blood glucose can cause

Hypoglycaemia
Hypoglycaemia can result from too tight a
control of both types of diabetes. The signs
and symptoms of hypoglycaemia and hyperglycaemia are described in Table 2 below.

Table 2: Symptoms of hypoglycaemia and hyperglycaemia and their treatment

Symptoms

Signs

Treatment

Hypoglycaemia:
Blood glucose
< 4mmol/L

Shaking
Weakness
Sweating
Headache
Hunger

Slurred speech
Aggression
Unusual behaviour
Confusion
Unsteadiness

Provide rapid acting

carbohydrate (e.g. 3 glucose
tablets, 50ml Lucozade),
immediately followed by
slow-releasing carbohydrate
(e.g. a sandwich or a couple
of slices of toast, banana) if
able to swallow. Glucogel
can also be used.
Unconscious patients may
need IV treatment and a
glucagon injection6

Hyperglycaemia
Blood glucose
> 10mmol/L

Extreme thirst and hunger

Needing to urinate
more often
Tiredness/lethargy
Blurred vision

Dehydration
Drowsiness
Frequent infection/unwell
Acetones on breath (pear
drop smell) suggesting
ketones
Rapid breathing

Check urine for ketones and

consider general wellbeing
of patient. If ketones present,
patient will need emergency
treatment to control glucose
levels. Adjustment of insulin
or oral medication may be
needed. Fluid intake is
important to prevent
dehydration6

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Short acting soluble insulin and rapid acting

insulin analogues are designed to mimic the
short burst of insulin that gets released when an
individual without diabetes eats a carbohydratecontaining meal.
Short acting soluble insulins are clear
solutions that are injected 15-30 minutes before
meals. They have a rapid onset of action (30-60
minutes), with peak action between two to four
hours, and can last for up to eight hours.
Rapid acting insulin analogues have been
modified by genetic engineering to give a faster
onset and shorter duration of action so that they
can be used immediately before or after a meal.
They are thought to be associated with a lower
risk of hypoglycaemia.
Intermediate and long acting insulins (also
referred to as basal insulins) provide a relatively
steady supply of insulin to maintain blood
glucose levels overnight and between meals,
mimicking the background insulin that is
produced by individuals without diabetes.
Isophane insulins are the traditional cloudy
insulins (Neutral Protamine Hagedorn [NPH]),
which are a suspension of insulin with
protamine. They require resuspension before
use, have a marked peak action profile and
variability in absorption, so there may be higher
risk of hypoglycaemia.
Long acting insulin analogues are formed
by altering the amino acid sequence to give a
prolonged duration of action. Their advantage is
that while the effect on HbA1c is similar to that
produced by NPH, there tends to be lower blood
glucose levels and a reduced risk of hypoglycaemia.

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Insulin detemir is associated with less weight
gain than insulin glargine or NPH. These are
often injected at bedtime but can also be given
in the morning.
Premixed (biphasic) insulins are a mixture
of short acting insulin or a rapid acting insulin
analogue with a longer acting protaminated
version of the same insulin in a fixed ratio. The
number in the name refers to the proportion of
short acting insulin in the mixture. These are
designed to ensure post-prandial needs are met
as well as ensuring hyperglycaemia between
meals and at bedtime is addressed. Like NPH
they are cloudy and need to be re-suspended.
Premixed insulins are usually given before
breakfast and the evening meal. Rapid acting
insulin-containing mixtures can be given just
before a meal, while short acting ones should
be given 15-30 minutes before a meal.

Case study no. 3

Mrs E, a 67-year-old Caucasian woman, comes
for her annual review for hypertension and you
have her blood results. She has developed type 2
diabetes in the past three years and is overweight. Her kidney function tests show that she
has an estimated glomerular filtration rate
(eGFR) of >60. The rest of the values are in the
normal range. Her cholesterol is 3.4mmol/L, her
BP is 162/88 mmHg and her current medication is
gliclazide 160mg, candesartan 16mg, furosemide
20mg each morning, and simvastatin 20mg
at night. Her HbA1c is 7.5 mmol/L. She brings
in a book of home blood glucose monitoring
results but does not know how to interpret them.
How would you manage this lady?

DAPNE and DESMOND

Dose Adjustment for Normal Eating (DAPNE) has been
introduced for patients with type 1 diabetes with patients
taking part obtaining, on average, a one per cent
improvement in HbA1c after six months treatment.
Similarly, Diabetes Education and Self-Management for
Ongoing and Newly Diagnosed (DESMOND) has been
introduced for patients with type 2 diabetes. Although it
did not lead to a reduction in HbA1c after 12 months, it was
associated with 1kg weight loss, five per cent less cigarette
smoking, a greater understanding of diabetes and lower
incidence of depression4.

HbA1c blood glucose control

Glucose in the blood binds irreversibly to a
specific part of haemoglobin in red blood cells,
forming HbA1c. Higher glucose readings
therefore result in higher HbA1c.
HbA1c circulates for the lifespan of the red
blood cell, reflecting the prevailing blood glucose
levels over the preceding two to three months.
The higher the HbA1c the greater the risk of longterm macro and microvascular complications.
From June 2009 people with diabetes have
had their measurement of HbA1c reported in
both percentage and millimoles. Both measurements will be reported until May 2011. The
revised target for HbA1c is 6.5 per cent or
4.8mmol/L.

Reflection exercise 3
Describe how services are provided to people with
diabetes in your locality. How might you work with other
healthcare professionals to improve the availability,
accessibility or quality of services to people with
diabetes?

compromised (increased risk of hypoglycaemia).

Sulphonylureas can be considered for those
patients not overweight.
If Mrs E starts metformin, her initial dose
should be 500mg daily, increased to a maximum
of 1g twice a day. Titrating the dose up slowly
limits GI side-effects, such as diarrhoea.
Both NICE7 and SIGN4 have updated their
guidelines for the management of patients with
diabetes and provided further detailed guidance.

Metformin
As Mrs E is overweight the best treatment choice
would be metformin. It does not cause weight
gain and there is strong evidence that it reduces
the risk of myocardial infarction and death in
diabetic patients. It works by reducing hepatic
glucose production and inhibiting intestinal
absorption of glucose. Glucose uptake by muscle
is also increased and there is increased glucose
utilisation by enhancing the action of insulin
at peripheral receptors. Mrs Es renal function
is normal so this is not a contraindication.
However kidney function should be monitored
as metformin is excreted renally; metformin
should be stopped if the eGFR falls below
30ml/min/1.73m2 or if there is a sudden
deterioration in kidney function. It is important
to remember that other medications, such as
NSAIDs and ACEIs, can also affect renal function.

Sulphonylureas
Sulphonylureas augment the bodys residual
insulin function by enhancing the release of
insulin from pancreatic islet cells and increasing
tissue sensitivity to insulin. They may also
increase the number of insulin receptors on
cells, so can cause hypoglycaemia. (Metformin is
unlikely to do this as it has no effect on insulin
release.) Gliclazide is short-acting and is an
appropriate choice for an elderly patient and
would be appropriate if renal function is

Meglitinides
Meglitinides (e.g. repaglinide and nateglinide)
stimulate insulin release in the presence of
glucose by closing the K+-ATP channels found on
the surface of pancreatic beta cells. This allows
for the postprandial glycaemic response, so they
need to be taken less than 30 minutes before
eating a meal. It suits those people who have
erratic lifestyles and do not eat regular meals.
Acarbose is an alpha glucosidase inhibitor
which prevents the breakdown of carbohydrate
in the GI tract, delaying digestion and the
absorption of glucose. Its use is limited by the
GI side-effects of diarrhoea, abdominal pain and
bloating and so is reserved for those patients
unable to tolerate other treatments.

DDP-4 inhibitors
DDP-4 inhibitors enhance the bodys levels of
incretin hormones (GLP-1 and gastric inhibitory
polypeptide [GIP]), which are normally released
from the intestine during a meal. They act on
the pancreas to increase meal-stimulated insulin
secretion and reduce glucagon secretion, thus
improving glycaemic control.
In the UK sitagliptin, vildagliptin and
saxagliptin are all licensed for dual therapy
with metformin, sulphonylureas or a thiazolidinedione. Sitagliptin is also licensed as
monotherapy and as triple therapy with met-

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Diabetic retinopathy
Diabetic retinopathy is a leading cause of blindness in the
developed world. There are often no symptoms in the
early stages of the disease, so patients should be advised
to have their eyes screened annually using digital retinal
photography to detect early changes. Over 60 per cent
of patients develop diabetic retinopathy within 20 years.
Tight control of BP and blood sugar has been shown to
be important10. Improving blood pressure control by
10mmHg systolic and 5mmHg diastolic over 8.4 years
resulted in a 37 per cent reduction in microvascular
complications including retinopathy.

formin and a sulphonylurea/thiazolidinedione.

They are weight neutral so may be preferable
to a thiazolidinedione. DDP-4 inhibitors are
generally well tolerated but there have been
reports from a recent meta-analysis of increased
incidence of infections, so long-term safety data
for these compounds are necessary.

Thiazolidinediones
Thiazolidinediones work by activating the
nuclear transcription factor peroxisome
proliferator-activated receptor gamma, turning
on and off specific genes for the regulation of
glucose, lipids and protein metabolism. They:
Enhance insulin sensitivity in muscle, liver
and adipose tissue
Decrease hepatic glucose production
Stabilise beta cell function.
There are safety concerns with both
rosiglitazone and pioglitazone. Neither should
be prescribed for patients with heart failure (as
they can cause fluid retention) or those at
increased risk of fracture. Rosiglitazone should
not be prescribed for those with previous or
current ischaemic heart disease as there is
evidence that it increases the risk of cardiac
ischaemia8.

Incretin mimetics
Incretin mimetics have similar activity to the
naturally occurring incretin GLP-1 hormone
and activate the human GLP-1 receptor.
Insulin secretion in beta cells is stimulated
and counteracts the hypersecretion of glucagon
in alpha cells, reducing hepatic glucose
production after a meal. Both these processes

CPD VI JULY 2010 PHARMACY MAGAZINE

are dependent on glucose so hypoglycaemia is

unlikely.
Incretin mimetics are associated with delayed
gastric emptying and promote weight loss.
Nausea and vomiting are the main side-effects,
reported in 40-50 per cent of cases, but tend
to be dose dependent and decrease in frequency
and severity over time. Acute pancreatitis has
been reported as a rare adverse effect.
Exenatide is injected twice daily before
breakfast and the evening meal, and liraglutide
once daily. The former is licensed for use with
metformin and/or sulphonylureas, as is
liraglutide, but can also be used in combination
with metformin and a thiazolidinedione. The
guidelines suggest that its place is third line as an
alternative to insulin for those who have a BMI
>30-35kg/m2. (The threshold will need to be
adjusted for ethnic groups that are at greater risk
of CVD.) It is recommended that treatment
should be monitored for its reduction of HbA1c
and also weight loss.

Insulin sites of injection

Lipohypertrophy is a common side-effect of insulin
therapy, characterised by swelling of subcutaneous
fat at the injection site. Caused by repeated injection
at the same site or reusing needles, patients should be
advised about rotating the site of injection and the correct
use of needles.

simvastatin 40mg with a target BP of

130/80mmHg9,10 and that, following an ACEI (or
ARB if an ACEI is not tolerated), a calcium
channel blocker or thiazide diuretic is added.
Beta blockers may be used when there is
ischaemic heart disease and the candesartan
dose could be increased. Renal function and
electrolytes should be checked before starting
and when increasing the dose; hyperkalaemia
and other side-effects of ACEI are commoner in
those with impaired renal function. Low-dose
aspirin is no longer recommended for primary
prevention in diabetes.

Peripheral vascular disease

Cardiovascular disease
Cardiovascular disease (CVD) is the commonest
cause of mortality amongst type 2 diabetic
patients causing approximately 80 per cent of
deaths. A patients risk of myocardial infarction
is that of someone who has already had a MI.
In relation to the previous case study, Mrs E
does not have impaired renal function so the
guidelines recommend that she should be on

Peripheral vascular disease (PVD) encompasses

diseases caused by occlusion of the major blood
vessels outside the heart and is commoner in
smokers. A common complaint is pain in the
legs when walking (intermittent claudication).
As well as managing BP and cholesterol, it is
important to address smoking in diabetes if the
patient is a smoker.

Diabetic nephropathy

Foot problems in diabetes

Diabetic foot problems are a common complication with a
prevalence of 23-42 per cent for neuropathy, nine to 23 per
cent for vascular disease and five to seven per cent for
foot ulceration. Amputation rates are higher in patients
with diabetes than patients without diabetes.
Neuropathy is a feature of diabetes that can affect
sensory, motor and autonomic functions. Distal sensory
neuropathy usually causes patients to lose the sensation
of vibration, so foot checks should be carried out annually.
Tests use 10g monofilament and palpation of pulses. The
presence of significant callus or structural abnormality or
previous ulceration increases the risk of ulceration4.
Diabetic foot problems are due to both microvascular
and macrovascular complications. SIGN has categorised
the risk of complications from diabetic foot and provided
guidance on management. Patients should be advised to
check their feet regularly and inside their footwear before
wearing, as peripheral neuropathy, which causes loss of
pain and sensation, means that trauma to the foot can
go unnoticed until significant damage has occurred. Such
ulcers tend to be deep but painless. Conversely, ischaemic
ulcers are painful and result from a reduced blood supply
to the feet, usually caused by peripheral vascular disease.
Ulcers are slow to heal (due to the poor supply of
nutrients and oxygen), occur at the distal ends of
the toes and are prone to infection. Staphylococcus
and streptococcus are the commonest organisms
implicated but swabs are usually taken from chronic
ulcers or those that are slow to heal to ensure the correct
antibiotic is used.

This is identified by detecting microalbuminuria

by measuring an albumin-creatinine ratio (ACR)
in urine. Threshold levels are 2.5mg/mmol for
men or 3.5mg/mmol for women. If larger
amounts of albumin are detected, then
proteinuria is diagnosed. This signifies more
severe renal damage. Proteinuria can progress
to end-stage renal disease, which may require
renal dialysis.
It is important to treat CVD risk factors for
these patients and further information can be
found in SIGN guidance on the management of
chronic kidney disease11. It is also a clinical area
that is monitored in the GMS contract in terms
of its identification and management.

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cpd module
Reflection exercise 4

CPD competences

Effecting any change to the care provided to diabetic

patients may require you to develop and implement a
new pharmacy service. What steps might you need to
take to introduce it successfully? (Issues to consider
include contractual frameworks, integration with other
healthcare professionals and local services, competences
required and communication with stakeholders.)

This module supports the following community pharmacy competences:

Competences

Where this module supports competence development

C1c

Reviewing medication with patients

to identify difficulties and potential
risks

The module identifies the problems with compliance that people with
diabetes exhibit and suggests ways pharmacists can help people better
understand their medication. Reflection exercise 1 encourages community
pharmacists to think about issues with medication in real and practical terms
and how these might impact on adherence and concordance, and consider
how they might address them

C2c

Creating and making use of

opportunities to encourage
healthy lifestyles

Ways in which people with diabetes can help to control their condition
through non-pharmaceutical means are identified. Areas where pharmacists
might provide advice and support with respect to the promotion of healthy
lifestyles are suggested and some of the psychosociological issues that
people with diabetes face and the role that pharmacy can play in signposting
diabetic patients to other professions are identified. Reflection exercise 2
encourages community pharmacists to review how people with diabetes
obtain support for managing their condition and consider how they can
provide additional support.

C4g

Working across professional

boundaries

The module outlines a multidisciplinary approach to supporting people with

diabetes. It encourages pharmacists to investigate and understand how
services are delivered and how they might interact. Reflection exercise 3 asks
pharmacists to investigate services in their locality and consider how they
might need to interact with other healthcare professionals to address service
needs

C5c

Developing and implementing new

services under local or national
contracts

Areas where pharmacists can provide services under the national and local
contracts are discussed. Reflection exercise 4 requires pharmacists to
consider the action that they might need to take to establish a new service
including considering issues such as contracting frameworks and
communication with other stakeholders

Home blood glucose monitoring

Mrs E has been advised to monitor her blood
glucose twice daily but she does not really know
what the results mean.
Home blood glucose monitoring is generally
only indicated for those patients managed with
sulphonylureas as they are at risk of hypoglycaemia. Recent research has shown that
inappropriate monitoring is harmful to the
patient, causing unnecessary anxiety and
increasing depression scores13. Mrs E should be
given some guidance on how to interpret the
results; for example higher readings may be
attributable after a meal due to intake of
specific food groups. Newly diagnosed patients
sometimes use this as a tool when learning
about different food groups and their effect on
blood glucose.
If Mrs E changes to metformin it is not
appropriate to continue with monitoring, as
metformin does not cause hypoglycaemia.
However she should have her feet checked each
year and have an annual check for retinopathy
(see footcare and retinopathy boxes).

Additional case study

Mr J comes into the pharmacy to pick up insulin for his
partner. Shes not feeling well today, he tells you. In fact
they think shes pregnant and assume a little morning
sickness is not unusual. They have just used a home
pregnancy test.
Mr J is right in that morning sickness is not unusual. But
the best advice would be for his partner to be referred to
a multidisciplinary team lead by an obstetrician, as adverse
pregnancy outcomes remain higher in those women with
diabetes. (This advice would apply for both type 1 and
type 2 diabetes.) It is important that good glycaemic
control is achieved during pregnancy as there are risks of
miscarriage, maternal infection, pre-eclampsia with foetal
and neonatal complications including congenital
malformation, late interuterine death, foetal distress and
hypoglycaemia.

References
1. Diabetes UK: www.diabetes.org.uk/guide-to-diabetes (accessed February 2010)
2. RPSGB. April 2010. Integrating community pharmacy into the care of people with diabetes: A practical resource.
www.betapharmacyplb.com/practice-science-and research/diabetes.asp (accessed April 2010)
3. Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications: WHO 2006
4. SIGN (2010) Management of Diabetes. www.sign.ac.uk/guidelines/fulltext/116 (accessed March 2010)
5. Diabetes Control and Complications Trial (DCCT) Research Group (1993). The effect of intensive treatment of diabetes on
the development and progression of long-term complications in insulin-dependent diabetes mellitus. NEJM 329:977-86
6. NHS Tayside Diabetes MCN (2009). The Tayside Diabetes Handbook. www.diabetes-healthnet.ac.uk/
HandBook/HandBook.aspx (accessed March 2010)
7. National Institute for Health and Clinical Excellence: NICE and Diabetes: A Summary of Relevant Guidelines.
November 2009. www.nice.org.uk/cg (accessed February 2010)
8. MHRA. Rosiglitazone and pioglitazone: cardiovascular safety and fracture risk. Drug Safety update 2007;1(3):10
9. Hansson L, Zanchetti A, Carruthers SG et al. Effects of intensive blood pressure lowering and low-dose aspirin in
patients with hypertension: principal results of Hypertension Optimal Treatment (HOT) randomised trial.
Lancet 1998; 351:1755-1762
10. United Kingdom Prospective Diabetes Study (UKPDS) group. 1998
11. SIGN (2009) Management of chronic kidney disease. Edinburgh
12. Farmer A, Wade A, Goyder E et al. Impact of self monitoring of blood glucose in the management of patients with noninsulin treated diabetes: open parallel group randomised trial. BMJ 2007 July 21; 335(7611): 132-40.
www.bmj.com/cgi/reprint/335/7611/132 (accessed April 2010)
13. OKane MJ, Bunting B, Copeland M and Coates VE. ESMON study group. Efficacy of self-monitoring of blood glucose in
patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ 2008 May 24; 336(7654):
1174-1177. www.bmj.com/cgi/reprint/336/7654/1174 (accessed April 2010)

REFLECT

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PLAN

Pharmacy Magazines CPD modules are now available on

Cegedim Rxs PMR systems, Pharmacy Manager and Nexphase.
Just click on the Professional Information & Articles button
within Pharmacy KnowledgeBase and search by therapy area.
Please call the Cegedim Rx helpdesk on 0870 841 1234 for
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CPD VII JULY 2010 PHARMACY MAGAZINE

ASSESSMENT

QUESTIONS

P H A R M A C Y M A G A Z I N E C P D R E C O R D J U LY 2 0 1 0
USE THIS FORM TO RECORD YOUR LEARNING AND ACTION POINTS FROM THIS MODULE ON
THE MANAGEMENT OF TYPE 2 DIABETES AND INCLUDE IT IN YOUR CPD PORTFOLIO
OR RECORD ONLINE AT WWW.UPTODATE.ORG.UK

Activity/development completed
(Act)

MANAGEMENT OF TYPE 2 DIABETES

1. How many people are
estimated to have a diagnosis
of diabetes in the UK in 2010?

5. Which oral antidiabetic

drug is associated with
weight loss?

a. 1.2m
b. 1.7m
c. 2.6m
d. 3m

a. Sulphonylureas
b. Metformin
c. Thiazolidinediones
d. Acarbose

2. Which is NOT a sign or

symptom of diabetes?

6. What is the lower

treatment target for HbA1c in
the updated NICE 2009/SIGN
2010 guidelines?

a. Polyuria
b. Weight loss
c. Tiredness or lethargy
d. Joint pain

3. Which of the following is

diagnostic of diabetes where
other symptoms are present?
a. A random venous
plasma glucose
concentration of
11.1mmol/L
b. A random venous
plasma glucose
concentration of
7.0mmol/L
c. A venous plasma
glucose concentration of
7.0mmol/L two hours
after a glucose tolerance
test
d. A fasting venous plasma
glucose of concentration
of 5mmol/L

4. Which is NOT a
complication of diabetes?
a.
b.
c.
d.

Cardiovascular disease
Retinopathy
Obesity
Kidney disease

a.
b.
c.
d.

Date:

Time taken to complete activity:

What did I learn that was new?

(Evaluate)

10 per cent
6.5 per cent
7.4 per cent
5.0 per cent

7. Identify the recommended

drug of choice to control
blood pressure in people with
diabetes who show signs of
nephropathy:

How have I put this into practice? (Provide examples of how learning has been applied what did you do differently as a result?)
(Evaluate)

a. Angiotensin II
antagonists
b. Thiazide diuretics
c. Beta blockers
d. ACE inhibitors

8. Which is NOT a myth about

diabetes?
a. People who are obese
are more likely to develop
diabetes
b. You can catch diabetes
from someone else
c. People with diabetes
are not allowed to drive
d. People with diabetes
cannot play sports

Do I need to learn anything else in this area?

(Reflect)

If as a result of completing your evaluation you have identified another new learning objective, start a new cycle
this will enable you to start at Reflect and then go on to Plan, Act and Evaluate. This form can be photocopied to
avoid having to cut this page out of the module.

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1.

a.

2.

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4.

a.

5.

a.

6.

a.

7.

a.

8.

a.

b.

b.

b.

b.

b.

b.

b.

b.

c.

c.

c.

c.

c.

c.

c.

c.

d.

d.

d.

d.

d.

d.

d.

d.

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177