These briefings have been developed for pharmacists and pharmacy teams working in England and Wales
Medicines optimisation is all about supporting patients so that they get the best possible outcomes from their medicines. It is about talking and engaging with individuals to understand their beliefs and concerns about their medicines and what they would like their medicine to achieve. It is also about ensuring that the medicine chosen is clinically appropriate, safe and effective and will help patients to achieve their goals; supporting patients to continue to use their medicines in a way that fits with their lifestyle.
To make medicines optimisation meaningful we need to engage with patients and involve them in decisions about their treatment. This may mean stopping medicines or providing non-medical treatment advice as well as starting medicines (PJ 2014;292:48).
The medicines optimisation briefings we have produced are for pharmacists working in all sectors of healthcare. We believe that, as experts in medicines and their use, pharmacy professionals are well placed to support patients to get the most from their medicines.
Medicines for type 2 diabetes
The briefing distributed with this week’s issue of The Journal focuses on medicines that are used for type 2 diabetes. This is the third in a series of briefings that complement and build on each other. The content is not intended to be exhaustive; the aim is to improve your approach to and understanding of patients who have type 2 diabetes. (Pharmacists should be aware that patients may have more than one condition and may be on a variety of different medicines.)
Patients with diabetes should be encouraged to self-manage their condition because this will result in more effective long-term control. All patients should see a specialist diabetes healthcare professional to help them to develop their care plan, personal goals and targets and have a say in every aspect of their care.
Patients should be encouraged to ask questions and request more information if they need to. Signposting to Diabetes UK and local support networks is an essential part of this.
Tips for pharmacists to help patients reduce the risk of developing type 2 diabetes and to support patients with the condition include the following:
Public health messages are key to preventing the development of type 2 diabetes. Up to 80 per cent of cases of type 2 diabetes can be delayed or prevented, and risk can be reduced by up to 60 per cent after making some basic lifestyle changes.
People are more at risk of developing type 2 diabetes if: they are overweight with a large waist size (over 80cm [31.5 inches] for women, 94cm [37 inches] for men, or 89cm [35 inches] for South Asian men); they have high blood pressure or a previous heart attack or stroke; or if they have a sedentary lifestyle.
Simple healthy living and dietary advice such as losing weight (if overweight or obese), healthy eating, increasing exercise or reducing alcohol intake can reduce the risk of developing type 2 diabetes and improve the outcomes of those people who have been diagnosed with type 2 diabetes by delaying the progression of the disease, the need for medication to control it and long-term complications such as cardiovascular disease, renal disease, stroke, amputation or blindness.
- Advise people and patients to set themselves realistic goals, mark their milestones and celebrate their successes
- Encourage people to try different things and vary their diet and exercise to avoid it becoming boring and tedious
- Make sure your staff are trained in providing opportunistic lifestyle advice to people
Every kilogram lost reduces the risk of type 2 diabetes by up to 15 per cent, so:
- Consider offering a weight management service
- Advise patients that regular meals help to keep blood glucose levels stable
- Advise patients to watch portion sizes — eating smaller amounts at main meals and snacks will help with weight loss and improve blood glucose levels
- Advise patients to include all the food groups every day, including at least five portions of fruit and vegetables, starchy carbohydrates (such as dairy, grainy bread, wholegrain cereal or oats, pasta, sweet potato or basmati rice) and a small amount of protein such as lean meat, chicken, fish, lentils and pulses
- Advise patients to choose low-GI snacks such as fruit, yoghurt, reduced fat cheese and wholegrain crackers or unsalted nuts
- Advise patients to limit unhealthy snacks high in salt, sugar or saturated fat — this is easier if people avoid processed foods and stick to fresh produce
- Complement a healthy diet with at least 30 minutes of exercise, five times a week — and avoid unhealthy food afterwards.
- Advise men to drink no more than 21 units of alcohol per week, no more than four units in any one day, and to have at least two consecutive alcohol-free days per week
- Advise women to drink no more than 14 units of alcohol per week, no more than three units in any one day, and have at least two consecutive alcohol-free days per week
- Make sure your customers, patients and staff know what a unit is — explain it in terms they can easily remember
- Have leaflets available to give out and signpost to websites and apps to help people to check their alcohol and calculate units, such as NHS Choices (www.nhs.uk/livewell/alcohol)
- Ask patients if they smoke —having diabetes already puts people at increased risk of heart disease and stroke, and smoking further increases this risk
- Offer patients smoking cessation advice when they are ready for it and signpost them to support groups
- Have “Quit kits” ready
- Encourage a one-off pneumococcal vaccination and annual influenza vaccination
- Reassure patients that starting medication does not mean they are failing. Type 2 diabetes is a progressive condition, but with good control patients can slow progression and reduce complications.
- Explain to patients that medication is not a cure for diabetes and will be needed for the long term. Although they may not have physical symptoms patients need to take or use their medicine(s) regularly as prescribed in order to prevent their condition from worsening and achieve long-term health benefits.
- Ensure patients know that medication is not a substitute for following a healthy diet and taking regular physical activity — they still need to carry on with this to reduce long-terms risks and improve outcomes (see “Lifestyle advice”).
- Patients with type 2 diabetes may have cardiovascular disease, so refer to previous advice about this (PJ 2014;292:212)
- Talk to patients about their care plan and monitoring. Have they been involved in setting their targets?
- Check what plans are in place for monitoring their condition and that patients know what checks have been done and how often checks should be repeated.
Patient-centred care is about listening, not telling, so:
- Discuss possible side effects with patients: how long they are expected to last for and what patients can do to minimise them. Ask patients to speak to you if they have any concerns or questions.
- Follow this up by asking patients how they are getting on when you next see them.
- Particularly check for episodes of hypoglycaemia, which may not be fully recognised in type 2 diabetes.
- Talk to patients about whether their medicines fit in with their daily routine; encourage them to talk to you about this rather than just stopping their medicines.
- Reassure patients that there are alternative choices of medicines available if they do not get on with them.
- Keep stocks of leaflets about type 2 diabetes to reinforce the information you have provided verbally.
- For patients who are on insulin, check that they are on the right preparation and ask if and how they adjust the dose.
- Check they know the correct injection technique, including the device, ensuring their injection sites and hands are clean and that they are rotating injection sites.
- Check they know how to store their insulin correctly and about safe disposal of syringes, needles and lancets.
- Check they know how to monitor their glucose levels and whom they can contact for advice.
- Check patients have a patient information booklet and insulin passport to help to provide accurate identification of their current insulin products.
- When dispensing prescriptions for insulin check this information to confirm the correct identity of insulin products.
- Find out more at: http://bit.ly/Oj35tM
- Ask patients if they are aware of the 15 healthcare essentials for the care they can expect for their diabetes — see www.diabetes.org.uk/15-essentials
Patients with type 2 diabetes should receive regular monitoring of their HbA1c levels. The National Institute for Health and Clinical Excellence advises to monitor every two to six months (according to individual needs) until patients are stable on unchanging therapy and to monitor six-monthly once blood glucose level and blood glucose lowering therapy are stable. You can:
- Encourage patients to maintain their individual target unless the resulting side effects (including hypoglycaemia) or their efforts to achieve this impair their quality of life.
- Offer lifestyle and medication advice to help achieve and maintain the HbA1c target level.
- Inform patients with a higher HbA1c that any reduction in HbA1c towards the agreed target is advantageous to future health.
Monitoring blood glucose and targets
There are many different opinions about whether patients with type 2 diabetes should or should not self-monitor their blood glucose routinely and what the ideal range is to aim for. The usefulness of self-monitoring is dependent on individuals, their medication, their ability and desire to self-manage their condition, and its value in informing decisions; for example, adjusting medication or making decisions about driving. NICE advises that self-monitoring of glucose levels should be available to patients on insulin treatment and to provide information on hypoglycaemia to patients taking oral glucose lowering medicines. It also helps them assess changes in glucose control resulting from medication and lifestyle changes, monitor changes during concurrent illness and ensure safety during activities, including driving. You can:
- Discuss the purpose of self-monitoring and how to interpret and act on the results with patients. If GPs prescribe testing strips for patients with type 2 diabetes, they should either be encouraged to test at different times during the day or week to get a picture of how diet, exercise and medication affect their blood glucose.
- Find out more at: http://bit.ly/1kS1SnI and http://bit.ly/1f02cf0.
- Make sure patients are aware of the Driver and Vehicle Licensing Agency (DVLA) regulations for diabetes and driving: see https://www.gov.uk/diabetes-driving
The DVLA requirements are explained well on the Diabetes UK website where there is a section on safe driving.
Medical professionals can find the latest medical standards for driving in the DVLA’s medical guidelines for professionals and at a glance guide (these guidelines are often updated and it is essential to check that the version being used is the most current).
- Speak to your commissioners about introducing public health services such as stop-smoking, weight management, alcohol brief advice or health checks services. Think about becoming a healthy living pharmacy.
Matthew Shaw, Anne Cole and Heidi Wright