The patient chosen to partake in this project is a 54 year old male of Asian origin, diagnosed 8 years ago, at 46 years old suffering from Type II Diabetes.
Diabetes Mellitus is a disorder that affects the endocrine system, as it is this system that controls and regulates the hormones (chemical messengers) release into their target cells. Therefore, diabetes is caused by irregular levels of insulin in the bloodstream. There are two types of the disease diabetes, type I and type II.
Type I diabetes is diabetes that occurs because the beta cells (those that produce insulin), of the pancreas are destroyed. It is known to be an autoimmune disease, initially recognised in patients under the age of 40, however, the disease can develop with age. The only treatment and method of survival for this type of diabetes is to be solely dependent on insulin.
Type II diabetes is caused by either insulin deficiency or body resistance to the insulin. As time progresses, extrinsic insulin treatment will be required to ensure the regulation of glucose in the bloodstream. Type II diabetes is most common in older people, especially those people that are obese and are of Asian nationality.
In a normal healthy person, when food is eaten it is digested and broken down into molecules of glucose which is absorbed into the bloodstream and into the cells that require it for energy. However to do this, insulin, a chemical messenger produced by the beta cells in the pancreas, is required to act as a key, complementary to the receptors on the plasmalemma of the glucose requiring cells. However, people suffering from diabetes may be producing the insulin required, yet the receptor becomes less responsive to the insulin or resistant to the insulin produced.
Additionally, receptor downregulation occurs which is a process whereby, in a patient that eats unhealthily there is extreme levels of glucose in the bloodstream so the body try’s to maintain and regulate homeostasis, so in a process of positive feedback, receptor downregulation occurs which increases the amount of glucose in the blood which is toxic. Furthermore, the body may start producing less insulin than required which prevents glucose entering the cells. Therefore, there is an accumulation of glucose in the bloodstream which leads to hyperglycaemia.
The main symptoms of the disease are:
Fatigue usually occurring because the patient is unable to use the glucose for energy.
Polyuria which is passing urine as the body tries to excrete the excess glucose from the body.
Nocturia, passing urine at night.
Blurry vision or decreased vision.
Slow healing of any cuts and wounds.
Polydipsia which is increased thirst.
Unusual weight loss as the body is unable to use the glucose for energy so the body breaks down the stored fat and proteins instead.
Itching, thrush or any urinary tract infections as generally the infection rate will increase as there are high levels of glucose in the blood stream.
Walker et al (2002): Clinical Pharmacy and Therapeutics, page 632 describes that the diagnosis of diabetes should not be based solely on one reading on a prick reading as they should be only used to identify people who may be at risk of diabetes such as screening. Diagnosis is usually established via a venous blood sample verified by thorough lab testing.
TALK ABOUT NICE GUIDELINES HERE for blood glucose levels for diagnosis of diabetes
The treatments that are generally used to control blood sugar levels are:
Lifestyle changes – the patient should be advised to introduce an exercise regime and suitable diet (there is no strict diet for diabetic patients, so patients are advised to eat healthily). However, if this cannot control the blood sugar levels then patients require oral antidiabetic drugs.
Oral Antidiabetic Drugs
Campbell, Ian (Jun 2007) Oral Antidiabetic Drugs: their properties and recommended use, Prescriber Volume 18 Issue 6 page 58 outlines the use of each antidiabetic drug.
First-line Drug Therapy
Types of Sulfonylureas include gliclazide, glibenclamide, glipizide and glimepiride, which work by stimulating the release of insulin into the bloodstream. As stated in the BNF (March 2010), Sulfonylureas must not be given to obese patients or overweight as these drugs can encourage weight gain. Also there is a very high risk of hypoglycaemia as some Sulfonylureas drugs (glibenclamide) are long acting and should NOT be prescribed to the elderly. Side effects include; nausea, vomiting, diarrhoea and constipation.
Types of Biguanide include metformin which improves insulin action. BNF (March 2010) describes that Metformin works differently to the Sulfonylureas drugs as it decreases the action of gluconeogenesis, therefore, limiting the amount of glucose being produced by substrates such as amino acids, glycerol etc. Metformin is usually given first priority to people who are overweight, so unlike Sulfonylureas drugs can be given to the elderly. Another benefit of this drug is that it does not lead to hypoglycaemia but has many more side effects including abdominal pain, anorexia and taste disturbance.
Second-line Drug Therapy
Glitazones (given with biguanides or sulfonylureas drugs as double therapy)
Types of glitazones include pioglitazone and rosiglitazone Glitazone drugs work to reduce the insulin resistance and improve the sensitivity to insulin. However, taking these drugs increases the risk of cardiovascular disease and many other side effects including reports of liver toxicity, alopecia, anaemia etc.
Prandial glucose regulators
Regulators include repaglinide and nateglinide. These second-line therapy drugs can be used as monotherapy or used with metformin. Sexton, John et.al (2006): Pharmaceutical Care made Easy, page 66 describes how these drugs work differently to the Sulfonylureas drugs, by stimulating the increase of insulin using different receptor sites. Side effects of this drug include abdominal pain, diarrhoea, vomiting, constipation and nausea.
There are three types of insulin that can be administered to treat diabetes.
Fast-acting insulin is insulin that is said to be neutral because they are soluble, working to reduce the glucose in as little as ten minutes but only work for a few hours so are suitable for patients that require insulin after a meal. Intermediate-acting insulin is insoluble insulin which takes about one to two hours to work effectively. To cover a whole day this insulin has to be injected twice daily. Long-acting insulin is insulin that lasts a whole day and so does not to be administered more than once each day.
Diabetes MUST be controlled to prevent serious microvascular and macrovascular complications which deter the health of the patient further.
Peripheral Neuropathy – this is when there is impairment or damage to the nerves, especially on the feet, leading to vibrations and muscle pain, eventually the patient will not be able to feel the feet at all.
Nephropathy – this is when the kidneys become swollen and larger than normal, because of excess fluid in the kidney and can be discovered by testing on urine for a certain chemical called albumin. If high amounts of this substance are found in the urine, then the patient is suffering from nephropathy which can lead to kidney failure.
Retinopathy – blindness in diabetic patients is common, therefore, regular screening is undertaken. Control over blood sugar can prevent retinopathy, and if detected early, the eyesight can be recovered by laser eye surgery.
Cardiovascular Disease – Walker, John et.al (2002) page 636 discusses that the risk of someone with diabetes having a myocardial infarction is the same as someone without diabetes having a second myocardial infarction. This highlights the importance of controlling diet and advising patients to stop smoking.
Peripheral Vascular Disease – this is when the blood vessels near the heart or around the heart are affected which increases the risk of suffering from a myocardial infaction or suffering from cardiovascular problems such as hypertension.
Microvascular and Macrovascular Diseases
Diabetic Foot Ulcers – this is the combined result of having many of the diseases above such as neuropathy, peripheral vascular disease and not controlling the amount of glucose levels in the bloodstream. Therefore, this leads to glucose deposits on the toes of the feet which become prone to infection. Therefore, patient education is of utmost importance to prevent ulcers appearing.
Social/Psychological Impairment and Management of the disease
The patient found coping with the disease very difficult, soon after diagnosis lost his job, unable to cope with the physical requirements and unable to drive the patient felt vulnerable and insecure, lost confidence and a sense of independence. Therefore, the patient fell in depression and financial worries increased .The family also felt that learning to manage the disease was difficult. However, education available provided the information required to deal with diabetic emergencies most common being hypoglycaemia which could lead to coma. Furthermore, the patient suffered from retinopathy which is a microvascular diabetic complications Therefore, in order to correct the patients eyesight the patient had to undergo a few laser treatments.
Role of Pharmacist
The pharmacist’s first and most important priority is the patient; hence the pharmacist initially must follow a certain care cycle and criteria to ensure maximum contribution to proper care of the patient. Therefore the patient’s care began with a broad assessment, gathering the information to identify symptoms, all problems and complaints and potential problems. This was when many of the symptoms of the patient were recognised as diabetic symptoms such as fatigue, passing urine excessively etc.
The pharmacist’s role at this point is to prioritise the patient and to advise and explain to the patient to see the patient as soon as possible. Once the patient was diagnosed the pharmacist was able to think about the outcomes of care and how to achieve the desirable outcomes. To do this, the pharmacist counselled the patient in accordance to the severity of the diabetes. The pharmacist at this point discussed lifestyle changes, such as moderate alcohol intake, maintaining a healthy diet, and introducing a sufficient exercise regime and the variety of antidiabetic drug therapy treatment options. Once the suitable drug therapy was identified for the patient, the pharmacist was able to provide and support the patient, by creating a rapport with the patient, providing and establishing self-confidence and asking questions. The pharmacist also counselled the patient by discussing each and every drug in an Medicines Use and Review (MUR) service which taught the patient how to administer insulin properly and effectively, the most common side effects, how to take medication and when to take medication (such as medication that must be taken with a meal or medications to be taken only in the morning etc.), and generally talking about how the patient is coping with the disease. The patient was also advised to join a diabetic clinic so that the patient and patient’s family could attend to receive important information about how to identify when a person is in a state of hypoglycaemia (eg. tremors, sweating, palpitations, drowsiness), and also giving details on how to avoid serious diabetic complications.
In general, the pharmacist has a duty of professional conduct to act in a way to benefit the patient which is publicised in the seven MEP Guidelines (YEAR).
Area for Improvement