MEDICINES USE REVIEWS FOR PATIENTS WITH DIABETES

MURs for Diabetic Patients OCT 2014

Please note for the purpose of this reference document Diabetes will be the main focus however as per HSC guidance: The medicines in the target group will identify if a patient is eligible for a MUR. In a MUR pharmacists need to consider all the medicines a patient is taking, including those that aren’t prescribed, and not just those that fall within the diabetes target group.

DIABETES is known to affect 2.9 million people in the UK, equating to 4.45% of

the population. Medicines as well as lifestyle changes play a key part in the management of both Type 1 and Type 2 diabetes. Pharmacists can play a significant role in improving patients’ knowledge of and adherence to prescribed medicines. This reference guide is designed to help improve the confidence of community pharmacy to provide high quality MURs for patients taking diabetes medicines. MURs can help to:

establish the patient’s actual use, understanding and experience of taking medicines

identify, discuss and assist in the resolution of poor or ineffective use of medicines by the patient

identify side effects and drug interactions that may affect the patient’s compliance with instructions given to them by a health care professional for the taking of medicines

improve clinical and cost effectiveness of medicines prescribed to patients In turn this can improve the ability of patients to manage their diabetes medication and condition effectively, promoting good diabetes control and minimising harm both short and long term.

Diabetes is caused by an absence of insulin, or a reduced sensitivity to insulin, which leads to raised blood glucose levels (hyperglycaemia). COMPLICATIONS of Type 1 and Type 2 diabetes are the same. Prolonged hyperglycaemia causes both microvascular (e.g.retinopathy) and macrovascular (e.g. cardiovascular) damage. • Cardiovascular for example, heart attacks, angina, stroke, peripheral artery disease • Kidney damage (nephropathy) sometimes leading to kidney failure • Eye problems (retinopathy) which can affect vision and lead to blindness • Nerve damage (neuropathy) that can cause a range of problems including neuropathic pain, foot problems, limb amputation and erectile dysfunction Microvascular complications are more common in people with Type 1 diabetes and macrovascular in people with Type 2 diabetes.

MEDICINES USE REVIEWS FOR PATIENTS WITH DIABETES

MURs for Diabetic Patients OCT 2014

HEALTHY LIVING ADVICE FOR PATIENT - MUR Smoking Do you smoke? Are you interested in quitting? Stopping smoking is the best thing that you can do for your health. Our Stop Smoking Service can help you to quit by helping to keep you motivated and providing stop smoking medicine. Weight How would you describe your weight? Managing your weight is important if you have diabetes and being in the right weight range can help with many aspects of your well-being. Exercise Do you take regular exercise? The Department of Health recommends that adults should do 150 minutes of moderate physical activity (such as cycling or fast walking) a week. How close are you to achieving this?

DIABETES MANAGEMENT Good blood glucose control is important to avoid the symptoms of diabetes and to prevent complications developing. Good control of blood glucose is maintained by aiming for glycosylated haemoglobin (HbA1c) level of below 48mmols/mol (Equivalent to 6.5% in the old nomenclature). For those at risk of severe hypoglycaemia, or for whom such tight control is not advised, the aim is a maximum of 59mmols/mol (or 7.5%). Diet and lifestyle Diet and lifestyle modification is integral to the management of diabetes. People with diabetes should be advised to: • Eat regular meals based around wholegrain, starchy foods • Eat at least five portions of fruit and vegetables per day • Reduce calorie intake if overweight and increase physical activity • Achieve and maintain a healthy weight • Reduce fat intake (particularly saturated fat) • Reduce sucrose intake • Reduce salt intake • Drink alcohol in moderation • Stop smoking Lifestyle interventions are first-line treatments for Type 2 diabetes but diabetes medication may be required if these do not manage the condition. Insulin is required for those with Type 1 diabetes.

MEDICINES USE REVIEWS FOR PATIENTS WITH DIABETES

MURs for Diabetic Patients OCT 2014

TYPE 2 DIABETES THERAPIES

Oral glucose-lowering drugs will have been initiated where blood glucose is

inadequately controlled (HbA1c ≥ 48mmol/mol) by lifestyle interventions of diet and exercise alone. If blood glucose control remains inadequate with insulin then the dose should be increased and the regimen intensified over time. Pioglitazone can be considered with insulin if a thiazolidenidione had previously had a marked glucose lowering effect or blood glucose control is inadequate with high-dose insulin.

1st line • Metformin is widely used as a first line oral therapy for all patients • A sulfonylurea (typically gliclazide) can be considered as an option where the person is not overweight; does not tolerate metformin; or requires a rapid response due to hyperglycaemic symptoms

2nd line (where blood glucose control remains or becomes inadequate with monotherapy) • Add sulfonylurea to metformin • Add dipeptidyl peptidase-4 (DPP-4) inhibitor (sitagliptin, valdagliptin) or thiazolidinedione (pioglitazone) to metformin if:

- the person is at significant risk of hypoglycaemia or its consequences - sulfonylurea is not tolerated or is contraindicated

• Add DPP-4 inhibitor or thiazolidinedione to sulfonylurea if metformin is not tolerated or is contraindicated

3rd line (where blood glucose control remains or becomes inadequate with dual therapy) • Add insulin to metformin and sulfonylurea (or to sulfonylurea and DPP-4 inhibitor or thiazolidinedione) particularly if the person is markedly hyperglycaemic • Add DPP-4, thiazolidinedione, or glucagon-like peptide-1 (GLP-1) analogue or mimetic (e.g. exenatide, liraglutide) to metformin and sulfonylurea when insulin is unacceptable or inappropriate

MEDICINES USE REVIEWS FOR PATIENTS WITH DIABETES

MURs for Diabetic Patients OCT 2014

DIABETES

MEDICINE HOW IT WORKS

WHY TAKING IT/BENEFITS

CONCERNS THAT

MIGHT AFFECT ADHERENCE

SOLUTIONS

Metformin (biguanide) Increased gradually to one tablet three times a day with or after food (maximum dose 2g per day in divided doses)

Helping the body to make better use of the lower amount of insulin it produces

• Controls symptoms of diabetes and prevents long-term problems • Used alone as first line treatment for many patients

Unwanted effects: feeling sick or being sick, diarrhoea, unusual taste, lack of appetite, abdominal pain • Dose frequency – may find it difficult to fit three times daily dose into lifestyle, or have problems remembering to take them

Unusual taste, lack of appetite, abdominal pain (with metformin) If these become troublesome, speak to the doctor Feeling sick or being sick • Common side effect of metformin that usually improves after a few days but if it continues, speak to the doctor • For other diabetes medicines, eat little and often and stick to simple foods. Taking the dose with food can also help Diarrhoea • Drink plenty of water to replace lost fluids • With metformin, usually improves as patient gets used to the medicine but speak to the doctor if it continues Constipation Eat a balanced diet with plenty of fibre and drink 6-8 glasses of water each day Cold and flu-like symptoms, headache, sore throat, aches and pains Speak to pharmacist to recommend an OTC treatment. Consult doctor if symptoms persist. Weight gain Maintain a balanced diet and discuss with doctor if feel gaining weight without eating more Ankle swelling Keep legs raised at rest Headache Take a simple painkiller such as paracetamol Lumpiness at injection site Rotate injection sites Hypoglycaemia Symptoms of hypoglycaemia include feeling hungry, trembling or shakiness, sweating, anxiety/irritability, palpitations and tingling of lips. Once you notice hypo symptoms you should take action straight way. Drink a glass of Lucozade or fruit juice, or eat five sweets (e.g. jelly beans). Follow this up with a longer acting carbohydrate such as half a sandwich or a bowl of cereal. If this is happening a lot then you should speak to your doctor.

Gliclazide and glimepiride (sulfonylureas) • Gliclazide – usually taken once daily 30 minutes before breakfast though it may be taken twice a day, according to the main meals of the day • Glimepiride – usually taken once daily shortly before or with first main meal of the day

Stimulate insulin production

• Controls symptoms of diabetes and prevents long-term problems • Used alone as first line treatment when metformin not appropriate • Added to metformin when that alone does not control blood sugar

Unwanted effects: hypoglycaemia, feeling sick or being sick, diarrhoea, constipation

Sitagliptin (DPP-4 inhibitor) Taken once daily

Works in part by increasing the amount of insulin produced by the body and also reduces the amount of a substance (glucagon) that causes the liver to produce sugar

• Controls symptoms of diabetes and prevents long-term problems • Added to metformin when that alone does not control blood sugar and a sulfonylurea not appropriate • Added to metformin and sulfonylurea when those together do not control blood sugar and insulin can’t be added

Unwanted effects: feeling sick or being sick, cold and flu like symptoms (headache, sore throat, aches and pain, upper respiratory tract infection), hypoglycaemia (particularly if taken with other diabetes medicines)

Pioglitazone (thiazolidinedione) Usually taken once daily

Helps the body to make better use of the lower amount of insulin it produces

• Controls symptoms of diabetes and prevents long-term problems • Added to metformin when that alone does not control blood sugar and a sulfonylurea not appropriate • Added to metformin and sulfonylurea when those together do not control blood sugar and insulin can’t be added

Unwanted effects: feeling sick or being sick, weight gain, ankle swelling, headache

Insulin Insulin is tailored to the patient’s needs and different types of insulin are given at different times of the day. May need to inject insulin several times a day or twice a day

Replaces the insulin that the body does not produce

• Controls symptoms of diabetes and prevents long-term problems • Used for Type 1 diabetes • Sometimes used in Type 2 diabetes when oral medicines alone have not controlled blood sugar

Unwanted effects: hypoglycaemia, lumpiness at injection site

MEDICINES USE REVIEWS FOR PATIENTS WITH DIABETES

MURs for Diabetic Patients OCT 2014

TYPE 1 DIABETES INSULIN THERAPY IN ADULTS Patients with Type 1 diabetes are prescribed insulin for control of blood glucose. • Multiple injection regimens Multiple injection regimens involve the use of a short-acting (soluble) or rapid acting insulin analogue (e.g. insulin aspart, insulin lispro, insuling glulisine) before meals, with intermediate (isophane insulin) or long-acting (insulin glargine, insulin detemir) given once or twice daily for basal insulin supply • Twice-daily insulin regimens Biphasic insulins (a mixture of short acting insulin or a rapid-acting insulin analogue with intermediate-acting or long-acting insulin) are given twice daily before meals

MOST COMMONLY PRESCRIBED INSULINS 1. Long Acting Analogues: Insulin Glargine (Lantus) / Insulin Detemir (Levemir) 2. Rapid Acting Analogues: Novorapid / Humalog / Apidra 3. Pre-Mix Insulins: Humulin M3 / Novomix 30/ Humalog mix 25/ Insuman Comb 25 4. Intermediate Insulins: Insulatard / Humulin I / Insuman Basal

MANAGING OTHER RISK FACTORS • Antihypertensives – if lifestyle advice does not reduce blood pressure to 140/80mmHg (or 130/80mmHg if there is kidney, eye or cerebrovascular damage) • Statins – dependent on CV risk status, a statin is recommended to achieve total cholesterol of

≤ 4.0mmol/l • Aspirin – low dose aspirin 75mg daily (or clopidogrel where there is clear aspirin intolerance) is offered to people with Type 2 diabetes aged 50 or over if blood pressure is below 145/90mmHg and to people under 50 with significant other CV risk factors (such as smoking and family history)

INJECTION TECHNIQUE • Insulin/ GLP-1 analogues is injected usually into the upper arms, thigh, buttocks or abdomen • Injection technique is important so that the insulin (or GLP-1 analogues) can be delivered correctly • Rotating injection sites can help prevent lumpiness developing at the injection site

HYPOGLYCAEMIA is defined as a blood glucose level of less than 4.0mmol/l. • Early symptoms include: sweating, palpitations, shaking, and hunger. • Late signs include confusion, drowsiness, odd behaviour, speech difficulty, lack of co-

ordination and coma.

Mild hypoglycaemia (where someone is able to treat themselves) should be treated to raise

blood glucose quickly. This could be 100ml Lucozade or 150ml of a non-diet fizzy drink or 3 or

more dextrose tablets or 4 large jelly babies or one tube (15g) of glucose gel.

For moderate to severe hypoglycaemia the use of glucose gel or glucagon may be necessary.

In severe hypoglycaemia (where the person needs help to treat it), if conscious and able to

swallow they should be offered one of the above treatments. If unconscious, the patient

should be put in the recovery position and 999 dialled.

MEDICINES USE REVIEWS FOR PATIENTS WITH DIABETES

MURs for Diabetic Patients OCT 2014

MUR CONSULTATION

Key Message: The purpose of the MUR is helping you better manage your diabetes and it gives you an opportunity to ask questions and raise any concerns. It is important to understand diabetes and benefits of treatment.

How are you getting on with your medicines? • Talk me through your medicines. • Do you ever take medicines that you have purchased, either from a pharmacy or anywhere else? Do you know why this medicine has been prescribed for you? • Tell me in your own words what you think it is for. How do you take or use each of these medicines? • How and when do you take your diabetes medicines? • How are you getting on with injecting yourself? • Do you test your blood glucose? If so, how often? • What do you do with the results? Are you having any problems with your medicines or concerns about taking or using them? • Do you think you are getting any side effects or unexpected effects? • Have you had any hypoglycaemic symptoms? • Have you missed any doses of your medicine or changed when you take it? Do you have anything else that you would like to ask about your medicines or is there anything that you would like me to go over again? • Are you happy with the information that you have on your medicines? • Diabetes medicines need to be taken/used regularly and at the correct time for it to be effective at preventing problems such as kidney damage or heart problems. • Do you have an Insulin Passport? • An Insulin Passport details your insulin and provides essential information and a safety check for prescribing, dispensing and administration.

RESOURCES AND REFERENCES: Diabetes UK - for Professionals NICE Guidance - Diabetes Pathway HSC Business Website - MUR documentation PIL - The Safe Use of Insulin for Patients with Diabetes Diabetes Matters Devon LPC Diabetes Toolkit