Muhammad Siddiqur Rahman highlights the integral role of practice-based pharmacists in managing type 2 diabetes

RAHMAN_Siddiqur_1

Siddiqur Rahman

GP Clinical Practice Pharmacist

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Read this article to learn more about:

  • the multidisciplinary approach to type 2 diabetes in general practice
  • what role pharmacists can have in patients’ initial and follow-up reviews
  • what resources are available to assist GPs, nurses, and pharmacists in the management of patients with type 2 diabetes.

In 2017, almost 3.7 million people in the UK had a diagnosis of diabetes, 90% of whom have type 2 diabetes.1 General practice is well placed to identify people who are at high risk of developing type 2 diabetes and to manage those for whom a diagnosis has been confirmed.2

Traditionally, the management of patients with type 2 diabetes has been in the hands of practice nurses and GPs, but this is being extended to the wider multidisciplinary team (MDT), including receptionists, administration clerks, healthcare assistants (HCAs), and now practice-based pharmacists, many of whom are also independent prescribers.

This article discusses the important role that practice pharmacists have in supporting:

Supporting people at high risk of type 2 diabetes

People who are at high risk of type 2 diabetes can be supported by practice pharmacists to reduce their risk.

How do you identify people at high risk?

Assessing risk of type 2 diabetes is a two-stage process:2

  • Stage 1—risk assessment
  • Stage 2—confirmation of risk
    • people considered at high risk should be offered a blood test to confirm whether they have type 2 diabetes or are at high risk (prediabetes).

Use a validated computer-based risk assessment tool to actively seek people on the practice register who may be at high risk, using data available in patients’ electronic health records. Patients attending reviews for existing conditions that increase risk of type 2 diabetes (such as cardiovascular disease, hypertension, obesity, stroke, polycystic ovary syndrome, a history of gestational diabetes, and mental health problems) should also be offered a risk assessment.2

Prediabetes is where a patient’s blood sugar levels are abnormally high, but lower than the threshold for diagnosing diabetes. Prediabetes implies possible impaired glucose metabolism and can be used to help identify people who are at high risk of developing type 2 diabetes; it is defined as:2

  • fasting plasma glucose 5.5–6.9 mmol/l, or
  • glycated haemoglobin (HbA1c) 42–47 mmol/mol (6.0–6.4%).

Note that HbA1c should not be used to diagnose diabetes in the following groups:3,4

  • children and young people (younger than 18 years of age) 
  • pregnant women or women who are less than 2 months postpartum 
  • people with symptoms of diabetes for less than 2 months 
  • people at high risk of diabetes, who are acutely ill
  • people taking medication that may cause hyperglycaemia (for example corticosteroids) 
  • people with acute pancreatic damage, including those who have had pancreatic surgery
  • people with end-stage chronic kidney disease
  • people with HIV infection.

Prediabetes may also be identified incidentally through NHS health checks, well-man or well-woman clinics run by HCAs or nurses, medical examinations by GPs, and routine review of pathology lab results by GPs and practice-based pharmacists.

People whose blood tests confirm that they are at high risk of developing diabetes should have the relevant read code assigned to their patient record.

What interventions should be offered?

Interventions should be appropriate to the patient’s risk of developing type 2 diabetes.2 People confirmed as being at high risk of developing type 2 diabetes should be offered:

  • information about their risk in an appropriate format, such as information packs developed by local diabetes charitable trusts5
  • an appointment with an HCA to discuss lifestyle and dietary adjustments
  • referral to a local 9-month NHS Diabetes Prevention Programme, to provide individualised lifestyle support to reduce the risk of developing type 2 diabetes.6,7

Some patients may require clinical intervention, especially if they are obese or cannot participate in an intensive lifestyle-change programme. These cases may be referred to the practice pharmacist, for example, for initiation of metformin to reduce cardiovascular risk, or orlistat for weight reduction.2

Supporting people newly diagnosed with type 2 diabetes

Diagnosis of type 2 diabetes can be guided by HbA1c; a threshold of 48 mmol/mol (6.5%) confirms the diagnosis, however, a value of <48 mmol/mol does not exclude diabetes diagnosed using glucose tests.8

Diagnosis of type 2 diabetes is usually made by the patient’s GP. At diagnosis, the GP will usually:

  • add the patient to the practice diabetes register
  • request screening tests (such as fasting lipids, thyroid function tests [TFTs], full blood count [FBC], liver function tests [LFTs], and urea and electrolytes [U&Es])
  • ask the patient to book a 40-minute newly diagnosed type 2 diabetes review with either the practice nurse or the practice pharmacist
  • ask the practice administrative team to register the patient to the local diabetic eye screening service (to monitor annually for diabetic retinopathy).

During the review

The review appointment should take place with the practice nurse or practice pharmacist after the results of the screening tests have been received.

Discuss the patient’s results

Discuss the patient’s test results and share them with the patient using Information prescriptions.9 Information prescriptions, developed by Diabetes UK, are information sheets designed to give people with diabetes the information that they need to understand, engage with, and improve on their health targets. The Information prescription can be tailored to the patient’s individual result and target during the review consultation, and can be used through primary care IT systems (EMIS Web, Vision, SystmOne) or downloaded from the Diabetes UK website.

The patient’s latest test results should be written into their individual record book with interpretations of what the results mean and how patients can improve their health outcomes.

Adopt an individualised care plan

NICE recommends that patients have an individualised care plan that takes into account their personal preferences, co-morbidities, risks from polypharmacy, and their ability to benefit from long-term interventions because of reduced life expectancy.10

Individualise treatment targets

Involve the patient in decisions about their individual HbA1c target (see Box 1), and encourage them to achieve this target and maintain it unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target, impair their quality of life.10

Measure the patient’s blood pressure. Arrange repeat measurements and offer lifestyle advice and treatment based on the patient’s blood pressure, cholesterol levels, and risk of developing cardiovascular disease (CVD) (see Boxes 2 and 3).10,11

If the patient is already on antihypertensive drug treatment when diabetes is diagnosed, review blood pressure control and the medication that the patient is taking—make changes only if there is poor control or if current drug treatment is not appropriate because of microvascular complications or metabolic problems.10

Box 1: Setting an individualised HbA1c target10

  • For adults with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%). For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%)
  • In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:
    • reinforce advice about diet, lifestyle and adherence to drug treatment and
    • support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and
    • intensify drug treatment
  • Consider relaxing the target HbA1c level … on a case-by-case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes:
    • who are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy
    • for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job
    • for whom intensive management would not be appropriate, for example, people with significant co-morbidities.

© NICE 2017 Type 2 diabetes in adults: management. Available from: www.nice.org.uk/ng28 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Box 2: Blood pressure management in people with type 2 diabetes10

  • Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice
  • For an adult with type 2 diabetes on antihypertensive drug treatment when diabetes is diagnosed, review blood pressure control and medications used. Make changes only if there is poor control or if current drug treatment is not appropriate because of microvascular complications or metabolic problems
  • Repeat blood pressure measurements within:
    • 1 month if blood pressure is higher than 150/90 mmHg
    • 2 months if blood pressure is higher than 140/80 mmHg
    • 2 months if blood pressure is higher than 130/80 mmHg and there is kidney, eye, or cerebrovascular damage.
  • Provide lifestyle advice (see Dietary advice and bariatric surgery section in type 2 diabetes in adults [NICE Guideline 28] and the Lifestyle interventions section in hypertension in adults [NICE Clinical Guideline 127]) if blood pressure is confirmed as being consistently above 140/80 mmHg (or above 130/80 mmHg if there is kidney, eye or cerebrovascular damage)
  • Add medications if lifestyle advice does not reduce blood pressure to below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular damage)
  • Monitor blood pressure every 1–2 months, and intensify therapy if the person is already on antihypertensive drug treatment, until the blood pressure is consistently below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye, or cerebrovascular damage)
  • First-line antihypertensive drug treatment should be a once-daily, generic angiotensin-converting enzyme (ACE) inhibitor. Exceptions to this are people of African or Caribbean family origin, or women for whom there is a possibility of becoming pregnant
  • The first-line antihypertensive drug treatment for a person of African or Caribbean family origin should be an ACE inhibitor plus either a diuretic or a generic calcium-channel blocker
  • A calcium-channel blocker should be the first-line antihypertensive drug treatment for a woman for whom, after an informed discussion, it is agreed there is a possibility of her becoming pregnant

For further details and the full list of recommendations, refer to NICE Guideline 28 on Type 2 diabetes in adults: management.10

© NICE 2017 Type 2 diabetes in adults: management. Available from: www.nice.org.uk/ng28 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Box 3: Primary prevention of cardiovascular disease for people with type 2 diabetes11

  • Use the QRISK2 risk assessment tool to assess CVD risk in people with type 2 diabetes
  • Offer atorvastatin 20 mg for the primary prevention of CVD to people with type 2 diabetes who have a 10% or greater 10-year risk of developing CVD. Estimate the level of risk using the QRISK2 assessment tool.

For further details and the full list of recommendations, refer to NICE Clinical Guideline 181 on Cardiovascular disease: risk assessment and reduction, including lipid modification.11

© NICE 2014 Cardiovascular disease: risk assessment and reduction, including lipid modification. Available from: www.nice.org.uk/cg181 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Discuss treatment strategies

Offer lifestyle advice and drug treatment to support adults with type 2 diabetes to achieve and maintain their HbA1c target.3

The decision on whether to commence on metformin or trial a diet-only approach should be made between the healthcare professional conducting the review and the patient and should include specific targets or goals within a certain timeframe for the patient to aim for.

Inform and educate

Offer the patient referral to the local structured education programme, and provide them with information about their diagnosis, such as a patient information pack from the local diabetes charitable trust (one example is the Paula Carr Diabetes Trust5).

Assess the risk of foot problems

Assess the patient’s risk of developing a diabetic foot problem in line with NICE Guideline (NG) 19 Diabetic foot problems: prevention and management.12 Check both feet for evidence of neuropathy, limb ischaemia, ulceration, callus, infection and/or inflammation, deformity, gangrene, and Charcot arthropathy. Ensure the patient is informed of their risk level both verbally and with a written information leaflet.12

Arrange regular review and screening

Inform the patient about what is included in an annual diabetes review, referring to the Diabetes UK 15 healthcare essentials (see Box 4).13 Clinicians may also find it useful to refer to the indicators for diabetes mellitus in the quality and outcomes framework (QOF).14

Liaise with the practice administrative staff to check that the newly diagnosed patient has been registered with the local diabetes eye screening service.

The clinician conducting the review should set up recall systems to:

  • arrange repeat blood tests
  • request a first-pass urine sample on the day of the patient’s review to check albumin:creatinine ratio (ACR)
  • remind patients to attend their annual diabetes reviews.

Box 4: Diabetes UK 15 Healthcare essentials for people with diabetes13

  1. Blood glucose test (HbA1c test)
  2. Blood pressure check
  3. Cholesterol check (for blood fats)
  4. Eye screening
  5. Foot and leg check
  6. Kidney tests
  7. Advice on diet
  8. Emotional and psychological support
  9. Diabetes education course
  10. Care from diabetes specialists
  11. Free flu jab
  12. Good care if you’re in hospital
  13. Support with any sexual problems
  14. Help to stop smoking
  15. Specialist care if you’re planning to have a baby.

Diabetes UK. Annual diabetes checks. Diabetes UK, 2018. Available at: www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/15-healthcare-essentials

Annual type 2 diabetes reviews

People with diabetes should have an annual review to help reduce their risk of serious diabetes complications. There are 15 checks, tests, and services that should be covered each year (see Box 4),13 and will help meet the indicators set by the QOF.14

Before the review appointment

The patient will receive a letter inviting them to their annual review around 1 month before it is due. The patient is asked to have a blood test to assess HbA1c, urea and electrolytes, and cholesterol in advance so that their results are available for analysis before the review appointment. The patient is also asked to collect a urine sample bottle so they can provide a first-pass morning urine sample on the day of their review.

Review lab results before the patient consultation

Prior review of the patient’s lab results by a practice pharmacist can help save significant time in the patient consultation. It is particularly helpful if the pharmacist provides notes to support the clinician conducting the review—these could be about abnormal results, possible treatment options, de-prescribing medication, or referral to secondary care.

During the review

The review is conducted by either the practice nurse or practice pharmacist and should be tailored to the patient’s specific preferences and their individualised care plan.10

Perform any remaining tests and assessments

Measure the patient’s blood pressure. Arrange repeat measurements and offer lifestyle advice and treatment based on the patient’s blood pressure, cholesterol levels, and risk of developing CVD (see Boxes 2 and 3).10,11

Assess the patient’s risk of developing a diabetic foot problem (see ‘Assess the risk of foot problems’ above).12

Ask if the patient has had their annual diabetes eye screening within the past 12 months.

The patient should have brought with them a first-pass morning urine sample, which should be sent to the lab to measure ACR.15

If microalbuminuria is detected, the GP will phone the patient to discuss the results. The patient would be invited back to commence treatment with an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), which can be initiated and titrated by a pharmacist prescriber.15

Discuss the patient’s results and targets

Discuss the patient’s pathology and assessment results in relation to their individual treatment targets. Use Information prescriptions13 to share relevant information and ensure that the patient’s blood test results, drug treatments, and targets are written in the patient’s care record booklet.9

Assess co-morbidities

Ask about co-morbidities (such as erectile dysfunction, mental health, chronic kidney disease, frailty, cardiovascular disease, heart failure). Keep these in mind when reviewing treatments.

Review treatment

Conduct a level 3 clinical medication review (a face-to-face review of medicines and conditions) with the patient. The nurse or pharmacist can prescribe or adjust the dosage of any medication that may be required within their scope of practice.16

NICE recommends that treatment is intensified if the patient is unable to achieve their individual HbA1c target, and targets should take any co-morbidities into consideration.10 Recent guidance from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes recommends that treatment choice is dictated by the patient’s co-morbidities, and that intensification of treatment is based on the patient-level characteristics at the time.17,18

If treatment intensification is required, the NICE patient decision aid,Type 2 diabetes in adults: controlling your blood glucose by taking a second medicine—what are your options?19 and the NICE Algorithm for blood glucose lowering therapy in adults with type 2 diabetes20 should be used to inform decisions.

The practice pharmacist should also review all medicines that the patient is currently taking, and aim to resolve any polypharmacy issues through de-prescribing inappropriate medications using evidence-based tools such as the STOPP START Criteria21 and the Beers Criteria.22

Help the patient to self-manage their diabetes

Discuss self-monitoring of blood glucose, particularly if patients are taking a sulfonylurea or are on insulin therapy.

Make sure the patient is aware of ‘sick day’ and hypoglycaemia guidance.

Reinforce lifestyle advice

Preventative lifestyle advice should be reinforced at every given opportunity. Patients should be offered referral to the local structured education course to make dietary and lifestyle interventions as a refresher.

Offer flu vaccination

If the review takes place during the winter months, offer the flu vaccination in the diabetes review. If it is not an appropriate time of year, make sure the patient is registered on the practice system so that they are invited for the vaccination at the appropriate time.

Set up recall for future reviews

Arrange a recall for the patient’s next annual diabetes review (and blood tests) and any other interim blood tests and reviews if required, for example, if there have been any changes to treatment or if further referral to secondary care is required.

As with the annual review, the practice pharmacist should review all the interim screening tests before the review meeting. All interim diabetes reviews are conducted by the practice pharmacist so that they can make any prescribing changes, in addition to offering the usual dietary and lifestyle advice.

Summary

Clinical practice pharmacists specialising in type 2 diabetes in primary care, can build a career in diabetes care. The UK Clinical Pharmacy Association (UKCPA) has developed An integrated career and competency framework for pharmacists in diabetes,23 which may be relevant to pharmacists wishing to specialise in this area.

Practice-based pharmacists can work successfully as part of the multidisciplinary general practice team to deliver excellent clinical care in the management of patients with diabetes. This has the potential to improve health outcomes for patients, provide value for money to practices (through meeting QOF indicators and cost-effective prescribing), while also significantly reducing GPs’ workload.

Muhammad Siddiqur Rahman

Clinical practice-based pharmacist prescriber, trainee Advanced Clinical Practitioner, Court View Surgery, Kent; Board Member of the Pharmacist Cooperative

References

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  5. Paula Carr Diabetes Trust. Supporting patients and healthcare professionals. Paula Carr Diabetes Trust, 2018. Available at: www.paulacarrdiabetestrust.co.uk/supporting-patients-and-healthcare-professionals/ (accessed 28 January 2019).
  6. NHS DPP Programme Support Team. NHS Diabetes Prevention Programme (NHS DPP)—primary care toolkit to support the local implementation of the NHS DPP. NHS England, 2016. Available at: www.england.nhs.uk/wp-content/uploads/2016/07/dpp-pc-toolkit.pdf (accessed 28 January 2019).
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  11. NICE. Cardiovascular disease: risk assessment and reduction, including lipid modification. Clinical Guideline 181. NICE, 2016. Available at: www.nice.org.uk/cg181
  12. NICE. Diabetic foot problems: prevention and management. NICE Guideline 19. NICE, 2015 (last updated 2016). Available at: www.nice.org.uk/ng19
  13. Diabetes UK. Annual diabetes checks. Diabetes UK, 2018. Available at: www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/15-healthcare-essentials (accessed 28 January 2019).
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  17. Davies M, D’Alessio D, Fradkin J et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2018; 61 (12): 2461–2498.
  18. Seidu S, Khunti K. Personalising treatment for type 2 diabetes: why is NICE so behind? Pharmaceutical Journal 2019; 11 (1): DOI 10.1211/CP.2019.20205921. Available at: www.pharmaceutical-journal.com/opinion/insight/personalising-treatment-for-type-2-diabetes-why-is-nice-so-behind/20205921.article (accessed 28 January 2019).
  19. NICE. Patient decision aid: Type 2 diabetes in adults: controlling your blood glucose by taking a second medicine—what are your options? NICE Guideline 28. Tools and resources. NICE, 2015 (last updated 2017). Available at: www.nice.org.uk/guidance/ng28/resources/patient-decision-%20aid-2187281197
  20. NICE. Algorithm for blood glucose lowering therapy in adults with type 2 diabetes. NICE Guideline 28. Tools and resources. NICE, 2015 (last updated 2017). Available at: www.nice.org.uk/guidance/ng28/resources/algorithm-for-blood-glucose-lowering-therapy-in-adults-with-type-2-diabetes-2185604173
  21. O’Mahony D, O’Sullivan D, Byrne S et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015; 44 (2): 213–218.
  22. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2015; 63 (11): 2227–2246.
  23. Ruszala V, Newland-Jones P, Kavanagh S et al. An integrated career and competency framework for pharmacists in diabetes. UKCPA, 2018 Available at: diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/2018-05/Diabetes%20ICCF%20May%2018.pdf (accessed 28 January 2019).