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Diabetes update

CPD

December 29, 2018

CPD credits

Accreditation Number : CAP1812D

Group 1 : 0.75 CPD credits

Group 2 : 1.5 CPD credits

This activity has been accredited for 0.75 hours of Group 1 CPD (or 0.75 CPD credits) suitable for inclusion in an individual pharmacist's CPD plan, which can be converted to 0.75 hours of Group 1 CPD (or 1.50 CPD credits) upon successful completion of relevant assessment activities.

Case scenario

Helen is a 63-year-old woman (height 162 cm, weight 84 kg) with chronic heart failure (NYHA Class 1), hypertension and type 2 diabetes (diagnosed five years ago).

The medicines Helen is currently taking is shown in the table (right), along with pathology results from one month ago.

Helen commenced glibenclamide around 12 months ago when her glycaemic control had been consistently suboptimal, despite taking metformin. She has been taking the current dose for 6 months, but her HbA1c has not reduced appreciably and she has gained 3 kg in weight.

Helen comes into the pharmacy to pick up her repeats, and discusses her diabetes control with you. She reports taking her medications daily and that gaining better control of her diabetes is a priority. However, she states: ‘I am not ready to start injecting myself and prefer to stick to pills.’ She wants to know more about the possibility of adding a third glucose-lowering agent.

This article presents an overview of options available to Helen, with an emphasis on recent evidence on the beneficial effects of some newer agents.

MEDICINE NAME AND STRENGTH	DIRECTIONS
Glibenclamide 10 mg	One tablet in the morning
Lisinopril 20 mg	One tablet in the morning

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Instead of saying . . .	Perhaps try . . .
Do you have any questions?	What questions do you have? (An example to prompt might be: Have you ever been worried about side effects or drug interactions?)
Take four times each day on an empty stomach	Taking a capsule four times a day on an empty stomach can be hard to organise. Can you explain for me how you will fit this into your daily meal routine for the next 5 days?
Do you take any other medicines?	This tablet can cause problems with some medicines, particularly antidepressants and diabetes medicines. What other medicines do you use?
Have you used this medicine before?	How effective has this medicine been for you in the past? OR If you had to give this medicine a score out of 10, what would it be?
Take this tablet every morning	When would you usually take your medicine?
Assumption . . .	Safer practice: Assume little to no knowledge with questions like . . .
Assuming patients know their medicines well	Why do you use that medicine? How do you take it? What time of day? Is it every day or just when you need it? How do you remember to take it regularly?
Assuming adverse effects are known to the patient	Have you ever experienced muscle soreness? What was the pain like (for muscle issues with statins)?
Directing what should happen when specific issues are identified	You’ve taken that PPI for X amount of time, but haven’t had any reflux symptoms for Y amount of time. As long-term use of PPIs can lead potentially to vitamin B12 deficiency and an increased risk of fractures from falls, would you be open to reducing the PPI dose, making it ‘when required’ or ceasing it altogether with an antacid or H2 antagonist on hand if needed?
What other medicines and natural supplements do you take (of which the GP may be unaware)?	Have I forgotten to ask about other medicines you might use? What others – vitamin supplements, puffers, creams, etc – do you use? What do you use for pain, say, for a headache or sore muscles? How often do you use these products? Have you bought anything else from the pharmacy lately?

Electronic prescription	A legal prescription that is wholly electronic in nature
Electronic Transfer of Prescription (ETP)	Involves the creation of an electronic message alongside the legal paper prescription. Upon scanning a barcode on the paper prescription, some prescription information from the PDS is downloaded to assist the pharmacy to supply the medicine. The pharmacy must have the legal paper prescription to supply the prescribed medicines
Active Script List (ASL)	A list displaying all active electronic prescriptions. On registration for an ASL, patients can also consent to having their existing active paper (ETP) prescriptions visible in their ASL, alongside their electronic prescriptions
Prescription Delivery Service (PDS)	A digital repository that houses and transmits electronic prescriptions and ETP between prescribing and dispensing

	ALLERGIC	VIRAL	BACTERIAL
Age group	Children or adults	More often in adults	More often in children
Aetiology	Allergen response	Usually associated with upper respiratory tract infections and commonly caused by adenovirus	Usually caused by Staphylococcus aureus, Streptococcus pneumoniae, or Haemophilus influenzae
Clinical features	Usually bilateral Common symptoms include itchy and watery or mucoid discharge	Usually unilateral, often becoming bilateral within days Common symptoms include red eye, watery or mucoid discharge and irritation	Usually unilateral but can be bilateral Common symptoms include red eye, purulent discharge and eyelid crusting

TOPICAL EYE PREPARATION	ADVERSE DRUG REACTIONS
Chloramphenicol	Hypersensitivity, burning, itching, dermatitis, aplastic anaemia (rarely)
Framycetin	Hypersensitivity, hearing impairment (rarely)
Ketotifen	Hypersensitivity, headache, punctuate keratitis, corneal erosion, irritation, pain, dry mouth, rash
Azelastine	Hypersensitivity, bitter taste, local irritation (burning and stinging)
Olopatadine	Hypersensitivity, headaches, local irritation, taste perversion, rhinitis, eyelid oedema, keratitis
Sodium cromoglycate	Hypersensitivity, eyelid swelling, transient stinging and burning, local irritation
Lodoxamide	Hypersensitivity, dizziness, headache, ocular discomfort, dry eye, pruritus, ocular hyperaemia

CLASS OF MUTATION	TYPE OF CFTR PROTEIN MUTATION	DESCRIPTION OF CFTR PROTEIN MUTATION
I.	No functional CFTR	No functional CFTR protein is produced, resulting in no CFTR channels at the cell surface
II.	Defective CFTR trafficking	Misfolded CFTR proteins are produced and these fail to reach the cell surface
III.	Defective CFTR gating	The CFTR proteins reach the cell surface, however there is an insu"cient opening of the channel gate
IV.	Decreased CFTR conductance	The CFTR proteins reach the cell surface and can open; however, due to the impaired shape of the CFTR protein, reduced quantities of chloride ions can pass through the channel
V.	Decreased CFTR production	A reduced quantity of CFTR proteins are produced, resulting in fewer CFTR proteins at the cell surface
VI.	Decreased stability of CFTR	The CFTR proteins reach the cell surface; however, instability of the proteins reduces their lifespan to function correctly

TRADITIONAL TREATMENTS IN CF	ROLE OF TREATMENT IN CF	EXAMPLES OF TREATMENTS USED IN CF*
RESPIRATORY SYSTEM
Mucus reduction (Inhaled therapies)	Osmotic agent – sodium ions draw water into the secretions resulting in thinner mucus	Sodium chloride 0.9%, hypertonic saline 6%
	Osmotic agent – hyperosmotic, therefore draws additional fluid into secretions	Mannitol
	Mucolytic agent – DNase enzyme slices the DNA in the mucus	Dornase alpha
Oral antibiotics	Anti-inflammatory in the lungs to slow decline in lung function	Azithromycin
	Antibacterial activity against P. aeruginosa	Ciprofloxacin
	Antibacterial activity against S. aureus	Flucloxacillin, dicloxacillin
	Antibacterial activity against S. maltophilia	Sulfamethoxazole/trimethoprim
Inhaled antibiotics	Antibacterial activity against P. aeruginosa	Tobramycin Colistimethate sodium
Intravenous antibiotics	Antibacterial activity against P. aeruginosa	Tobramycin, ceftazidime, cefepime, piperacillin/tazobactam, aztreonam, meropenem
Intravenous antibiotics	Antibacterial activity against methicillin-sensitive S. aureus	Flucloxacillin, piperacillin/tazobactam, cefepime
Inhaled bronchodilators	Bronchodilation of the airways	Salbutamol
Inhaled corticosteroids	Reduce inflammation in the airways	Budesonide, ciclesonide, fluticasone
Antifibrinolytic	Treat haemoptysis from excess coughing	Tranexamic acid
GASTROINTESTINAL SYSTEM
Pancreatic enzymes	Replacement enzymes to treat pancreatic insufficiency	Pancrelipase
Fat-soluble vitamins	Supplementation of vitamins A, D, E, K	Multivitamins with A,D,E,K
GORD	Alleviate symptoms of re!ux featured in GORD	Omeprazole, esomeprazole, pantoprazole, famotidine Aluminium hydroxide and magnesium carbonate
Vitamins and minerals	Supplementation of vitamins and minerals	Cholecalciferol, calcium, magnesium, zinc
Laxatives	To treat and prevent DIOS	Macrogol, lactulose, docusate with senna, bisacodyl
Insulin	To treat insulin insufficiency in CF-related diabetes	Multiple insulin forms
HEPATIC SYSTEM
Bile sequestrant	Improves bile acid flow	Ursodeoxycholic acid
NASAL PASSAGE
Intranasal saline	Sinus rinse to clear nasal passage	Normal saline
Intranasal corticosteroid	Reduce inflammation in the nasal passages from chronic sinusitis	Budesonide
SWEAT GLANDS
Salt replacement	Replacing loss of salt and maintaining hydration	Sodium chloride tablets

CFTR MODULATOR GENERIC NAME/ BRAND NAME*	TYPE OF CFTR MUTATION	ADULT DOSAGE		CYP ENZYME INTERACTIONS	ACCESS TO MEDICATION**
CFTR MODULATOR GENERIC NAME/ BRAND NAME*	TYPE OF CFTR MUTATION	MORNING	EVENING	CYP ENZYME INTERACTIONS	ACCESS TO MEDICATION**
Ivacaftor *Kalydeco*	Defective CFTR channel gating	Ivacaftor 150 mg 1 tablet	Ivacaftor 150 mg 1 tablet	Ivacaftor: substrate of CYP3A4/5	PBS written authority required S100
Lumacaftor/Ivacaftor *Orkambi*	Defect in CFTR tra!cking (including F508del)	Lumacaftor/ivacaftor 200 mg/125 mg 2 tablets	Lumacaftor/ Ivacaftor 200 mg/125 mg 2 tablets	Lumacaftor: strong inducer of CYP3A4/5 Ivacaftor: substrate of CYP3A4/5	PBS written authority required S100
Tezacaftor/Ivacaftor + Ivacaftor *Symdeko*	Defect in CFTR trafficking (including F508del)	Tezacaftor/ivacaftor 100 mg/150 mg 1 tablet	Ivacaftor 150 mg 1 tablet	Ivacaftor: substrate of CYP3A4/5 Tezacaftor: substrate of CYP3A4/5	PBS written authority required S100
Elexacaftor/Tezacaftor/ Ivacaftor + Ivacaftor *Trikafta*	Defect in CFTR tra!cking (including F508del)	Elexacaftor/tezacaftor/ ivacaftor 100 mg/50 mg/75 mg 2 tablets	Ivacaftor 150 mg 1 tablet	Elexacaftor: substrate of CYP3A4/5 Tezacaftor: substrate of CYP3A4/5 Ivacaftor: substrate of CYP3A4/5	Compassionate access only

Preparing yourself and your staff

Ensure an efficient service

Medicine-related issues post-discharge

Becoming a GP pharmacist

Community pharmacists gearing up

Priority population

State response

Approval for AstraZeneca

Victorian lockdown lifted

Support for pharmacists

Self-care strategies

Impact on patients

Counselling advice

Efficacy of treatment

Collaborating with allied health professionals

Pharmacists critical to rollout

A lack of knowledge

Pharmacist intervention

Flying blind

Words matter

A patient’s perspective

Body language is important

ILWOO PARK MPS

Bridging the gap

Instead of saying . . .

Perhaps try . . .

Assumption . . .

Safer practice: Assume little to no knowledge with questions like . . .

Pharmacies a 'vital link'

Pfizer hubs announced

Introduction

Learning objectives

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Electronic prescriptions

Conclusion

Key points

Learning objectives

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Introduction

The prostate

Aetiology and pathophysiology

Signs and symptoms

Diagnosis

Management

Pharmacotherapy

Prognosis

Role of the pharmacist

Support services

Conclusion

Key points

Case scenario continued

Case scenario

Learning objectives

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Introduction

Background

Infective causes

Helpful links

Non-infective causes

What are the differential diagnoses?

When is referral required?

Management

Role of the pharmacist

Conclusion

Key points

Case scenario continued

Learning objectives

Extended learning activity

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS. Read the full cystic fibrosis here.

Introduction

Learning objectives

Extended learning activity

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS. Submit answers for the EXTENDED LEARNING ACTIVITY here.

Epidemiology

Diagnosis

Pathophysiology

Pharmacological management

Non-pharmacological management

Role of the pharmacist

Conclusion