Structured patient education for people with type 2 diabetes the X-PERT Programme

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1 Structured patient education for people with type 2 diabetes the X-PERT Programme Item type Authors Publisher Journal Article McLaughlin, Ann Sally Green Cross Publishing Nursing in General Practice Downloaded 23-Apr :36:50 Link to item Find this and similar works at -

2 Structured patient education for people with type 2 diabetes the X-PERT Programme Sally-Ann McLaughlin, Senior Community Dietitian, Community Nutrition and Dietetic Services of the Health Promotion Department, HSE Dublin North East There is currently an estimated population of 130,000 people (4.3%) 1 living with diabetes in the Republic of Ireland and this number is expected to rise by 37% over the next five years. Diabetes is a costly condition both for the patient, in terms of quality of life and long term complications and for the health system, in terms of economic burden. The healthcare cost of looking after people with diabetes is very high accounting for 5-15% of our health expenditure. 2 Structured education Education of adults with diabetes is changing; in response to validated scientific evidence that promotes what is now termed a structured approach to diabetes education. Research shows that structured education programmes, as defined NICE (2003), 3 based on client centred models of care increase and promote self management. People with diabetes are empowered to become actively involved in their treatment by increasing confidence, skills and knowledge. Self management is a vital component of a high quality diabetes service. 2,4,5 People with diabetes see a health professional for approximately three hours a year and rely on themselves for the other 8,757 hours. The X-PERT programme is one example of a structured patient education programme successfully being rolled out across Ireland by the community nutrition and dietetic services. The X-PERT programme X-PERT aims to empower clients to make informed decisions regarding their diabetes self-management. The X-PERT (Expert Patient Education versus Routine Treatment) programme is a dietitian led, group-based, structured education programme for people with type 2 diabetes (2.5 hour sessions x 6 consecutive weeks (15hrs)). The delivering dietitians are quality assured adult educators skilled in different education/teaching methods, behavioral therapy, motivational interviewing, adult learning etc. It is an evidence-based, audited, quality assured, HSE national achievements award winner (2008) and meets the NICE key criteria for structured patient education and is NHS approved. 3 X-PERT has been evaluated via randomised controlled trial 6,7,8 and impacts positively on clinical, lifestyle and psychosocial outcomes. What is the X-PERT programme all about? This new to Ireland patient-centered, group-based approach to patient education actively encourages participants to discuss and explore their own experiences of living with diabetes. This helps participants to adapt the key messages of diet and lifestyle modification and apply them to their personal circumstances. After the six week programme, participants are offered refresher sessions within the following six months and an annual update session thereafter. This continuing education and support of lifestyle changes is in line with strong evidence for the value of patient follow up in chronic disease management. 9 X-PERT Ireland In 2005 the Community Nutrition and Dietetic Service, HSE South, began liaison with the X-PERT UK to adapt the programme for Ireland. To date (Figures taken from data entered by May 27 th 2010), 79 community dietitians from the four HSE regions of Ireland have been trained as X-PERT Ireland Educators. 101 programmes have been delivered across the Republic of Ireland, educating 1189 people with type 2 diabetes. 88.1% of clients have attended four or more of the six sessions. The mean number of session attended is five out of six. The mean participant evaluation score for the programme was 95.8%. Clinical and empowerment data, as displayed in Table 1, shows positive improvements in biochemical and physiological parameters, similar to those seen in Irish and UK trials and in line with audit standards set out for X-PERT. HSE investment in promoting X-PERT has highlighted the importance of linking with health professionals who are supportive of integrated diabetes care in the wider primary care network. X-PERT has also raised professionals awareness, knowledge, confidence, diabetes management skills and partnerships in improving the care and service s for people with type 2 diabetes. 27

3 Week Week 1 Content What is diabetes? Self monitoring of blood glucose Understanding medication Diabetes health results what do they mean? Week 2 Weight management; energy balance Healthy eating and portion control Physical activity Week 3 Carbohydrate awareness What are carbohydrates? How starches and sugars affect blood glucose levels Dispelling myths of the sugar-free diet Week 4 Reading food labels (supermarket tour). A virtual supermarket is created giving clients an opportunity to ask questions, read labels and become more informed about the foods they eat. Week 5 Possible complications of diabetes short and long-term Prevention of complications Living with diabetes Week 6 Refreshers and annual sessions Are you an X-PERT? Game designed to recap on main messages of the programme in a fun way while helping to increase skills, knowledge and confidence in making informed decisions regarding diabetes self-management. Questions and answers Comments and feedback Sharing of resources Recap on aspects of 6 week programme as per patient requests Further goal setting 20 minutes at end of each week goal setting with five step empowerment model. Summary The X-PERT programme is proven to be cost, time and resource efficient. Clients are extremely happy with the service. 89% of clients (surveyed in the Dublin North East region) reported that having attended X-PERT, it has inspired them to support others with diabetes in their community. Clients are now actively involved in their own treatment. They are taking responsibility and action for their health and lifestyles and maintaining changes for one year and longer after participating on the programme. Comments from participants after attending the X-PERT programme For the first time in my life I feel like I am the one in control of my diabetes. The programme really helped me and my family take a better look at our lifestyle. After 23 years with type 2, it s the first time I ve really been informed in detail about my condition. Without this programme I would remain ignorant to my diabetes. Comments from GP whose clients attended the X-PERT programme We undoubtedly feel our patients are more empowered to take proactive steps in managing their disease (with improved knowledge, compliance with drugs, increased awareness about diabetes) and are hopeful this will significantly improve the disease burden for individuals and health providers in the future. 28

4 JANUMET for powerful glucose reductions 1 For patients not at goal on metformin alone In clinical studies of patients with type 2 diabetes, Powerful and sustained HbA 1c reductions over 1 year 1,2 Weight loss and less hypoglycemia vs an SU * + metformin (with sitagliptin 100 mg + metformin) 3 3-D Control: comprehensive mechanism of action targets 3 key defects of type 2 diabetes 1 (sitagliptin/metformin) Changing the course to glucose control. Janumet 50mg/850mg and Janumet 50mg/1000mg film-coated tablets (50 mg of sitagliptin as phosphate monohydrate and 850 mg or 1000mg of metformin hydrochloride). ABRIDGED PRODUCT INFORMATION Refer to Summary of Product Characteristics before prescribing. PRESENTATION Janumet 50mg/850mg film-coated tablets: Capsule-shaped, pink film-coated tablet with 515 debossed on one side containing 50 mg of sitagliptin as phosphate monohydrate and 850 mg of metformin hydrochloride. Janumet 50mg/1000mg film-coated tablets: Capsule-shaped, red film-coated tablet with 577 debossed on one side containing 50 mg of sitagliptin as phosphate monohydrate and 1000 mg of metformin hydrochloride. USES For patients with type 2 diabetes mellitus: Janumet is indicated as an adjunct to diet and exercise to improve glycaemic control in patients inadequately controlled on their maximal tolerated dose of metformin alone or those already being treated with the combination of sitagliptin and metformin. Janumet is indicated in combination with a sulphonylurea (i.e., triple combination therapy) as an adjunct to diet and exercise in patients inadequately controlled on their maximal tolerated dose of metformin and a sulphonylurea. Janumet is also indicated as triple combination therapy with a PPARγ agonist (i.e., a thiazolidinedione) as an adjunct to diet and exercise in patients inadequately controlled on their maximal tolerated dose of metformin and a PPARγ agonist. Janumet is also indicated as add-on to insulin (i.e., triple combination therapy) as an adjunct to diet and exercise to improve glycaemic control in patients when stable dosage of insulin and metformin alone do not provide adequate glycaemic control. DOSAGE AND ADMINISTRATION The dose of antihyperglycaemic therapy with Janumet should be individualised on the basis of the patient s current regimen, effectiveness, and tolerability while not exceeding the maximum recommended daily dose of 100 mg sitagliptin. For patients not adequately controlled on metformin alone, the usual starting dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) plus the dose of metformin already being taken. For patients switching from co-administration of sitagliptin and metformin, Janumet should be initiated at the dose of sitagliptin and metformin already being taken. For patients inadequately controlled on dual combination therapy with the maximal tolerated dose of metformin and a sulphonylurea, the dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken. When Janumet is used in combination with a sulphonylurea, a lower dose of the sulphonylurea may be required to reduce the risk of hypoglycaemia. For patients inadequately controlled on dual combination therapy with the maximal tolerated dose of metformin and a PPARγ agonist, the dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken. For patients inadequately controlled on dual combination therapy with insulin and the maximal tolerated dose of metformin, the dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken. When Janumet is used in combination with insulin, a lower dose of insulin may be required to reduce the risk of hypoglycaemia. All patients should continue their diet with an adequate distribution of carbohydrate intake during the day. Overweight patients should continue their energy-restricted diet. Janumet should be given twice daily with meals to reduce the gastrointestinal undesirable effects associated with metformin. Use in renal insufficiency: Janumet should not be used in patients with moderate or severe renal impairment (creatinine clearance < 60 ml/min). Use in hepatic insufficiency: Janumet should not be used in patients with hepatic impairment. Use in elderly: Janumet should be used with caution as age increases. Monitoring of renal function is necessary to aid in prevention of metformin-associated lactic acidosis. Limited safety data on sitagliptin is available in patients > 75 years of age and care should be exercised. Use in children: Not recommended for use in children below 18 years of age. CONTRAINDICATIONS hypersensitivity to the active substances or to any of the excipients diabetic ketoacidosis, diabetic pre-coma moderate and severe renal impairment (creatinine clearance < 60 ml/min) acute conditions with the potential to alter renal function such as: dehydration, severe infection, shock, intravascular administration of iodinated contrast agents acute or chronic disease which may cause tissue hypoxia such as: cardiac or respiratory failure recent myocardial infarction, shock hepatic impairment acute alcohol intoxication, alcoholism lactation. PRECAUTIONS Janumet should not be used in patients with type 1 diabetes and must not be used for the treatment of diabetic ketoacidosis. Lactic acidosis: It is a very rare serious metabolic complication that can occur due to metformin accumulation. Reported cases of lactic acidosis in patients on metformin have occurred primarily in diabetic patients with significant renal failure. The incidence of lactic acidosis can and should be reduced by also assessing other associated risk factors. If metabolic acidosis is suspected, treatment with the medicinal product should be discontinued and the patient hospitalised immediately. Renal function: As metformin-related lactic acidosis increases with the degree of impairment of renal function, serum creatinine concentrations should be determined at least once a year in patients with normal renal function and at least two to four times a year in patients with serum creatinine levels at or above the upper limit of normal and in elderly patients. Decreased renal function in elderly patients is frequent and asymptomatic. Special caution should be exercised in situations where renal function may become impaired, for example when initiating antihypertensive or diuretic therapy or when starting treatment with a nonsteroidal anti-inflammatory drug (NSAID). Hypoglycaemia: Patients receiving Janumet in combination with a sulphonylurea or with insulin may be at risk for hypoglycaemia. Therefore, a reduction in the dose of the sulphonylurea or insulin may be necessary. The use of Janumet in combination with insulin has not been adequately studied. Hypersensitivity reactions: Postmarketing reports of serious hypersensitivity reactions in patients treated with sitagliptin have been reported. These reactions include anaphylaxis, angioedema, and exfoliative skin conditions including Stevens-Johnson syndrome. Onset of these reactions occurred within the first 3 months after initiation of treatment with sitagliptin, with some reports occurring after the first dose. If a hypersensitivity reaction is suspected, discontinue Janumet, assess for other potential causes of the event, and institute alternative treatment for diabetes. Surgery: As Janumet contains metformin hydrochloride, the treatment should be discontinued 48 hours before elective surgery with general, spinal or epidural anaesthesia. Janumet should not usually be resumed earlier than 48 hours afterwards and only after renal function has been re-evaluated and found to be normal. Administration of iodinated contrast agent: The intravascular administration of iodinated contrast agents in radiological studies can lead to renal failure which has been associated with lactic acidosis in patients receiving metformin. Therefore, Janumet should be discontinued prior to, or at the time of the test and not reinstituted until 48 hours afterwards, and only after renal function has been re-evaluated and found to be normal. Change in clinical status of patients with previously controlled type 2 diabetes: A patient with type 2 diabetes previously well controlled on Janumet who develops laboratory abnormalities or clinical illness (especially vague and poorly defined illness) should be evaluated promptly for evidence of ketoacidosis or lactic acidosis. Evaluation should include serum electrolytes and ketones, blood glucose and, if indicated, blood ph, lactate, pyruvate, and metformin levels. If acidosis of either form occurs, Janumet must be stopped immediately and other appropriate corrective measures initiated. Drug interactions: Co-administration of multiple doses of sitagliptin (50 mg twice daily) and metformin (1,000 mg twice daily) did not meaningfully alter the pharmacokinetics of either sitagliptin or metformin in patients with type 2 diabetes. There is increased risk of lactic acidosis in acute alcohol intoxication (particularly in the case of fasting, malnutrition or hepatic insufficiency) due to the metformin active substance of Janumet. Consumption of alcohol and medicinal products containing alcohol should be avoided. Cationic agents that are eliminated by renal tubular secretion (e.g., cimetidine) may interact with metformin by competing for common renal tubular transport systems. Therefore, close monitoring of glycaemic control, dose adjustment within the recommended posology and changes in diabetic treatment should be considered when cationic agents that are eliminated by renal tubular secretion are co-administered. The intravascular administration of iodinated contrast agents in radiological studies may lead to renal failure, resulting in metformin accumulation and a risk of lactic acidosis. Therefore, Janumet should be discontinued prior to, or at the time of the test and not reinstituted until 48 hours afterwards, and only after renal function has been re-evaluated and found to be normal. Combination requiring precautions for use: Glucocorticoids (given by systemic and local routes) beta-2-agonists, and diuretics have intrinsic hyperglycaemic activity. The patient should be informed and more frequent blood glucose monitoring performed, especially at the beginning of treatment with such medicinal products. If necessary, the dose of the anti-hyperglycaemic medicinal product should be adjusted during therapy with the other medicinal product and on its discontinuation. ACE-inhibitors may decrease the blood glucose levels. If necessary, the dose of the anti-hyperglycaemic medicinal product should be adjusted during therapy with the other medicinal product and on its discontinuation. Effects of other medicinal products on sitagliptin: Clinical data described below suggest that the risk for clinically meaningful interactions following co-administration of other medicinal products is low. Cyclosporin: A study was conducted to assess the effect of cyclosporin, a potent inhibitor of p-glycoprotein, on the pharmacokinetics of sitagliptin. Co-administration of a single 100 mg oral dose of sitagliptin and a single 600 mg oral dose of cyclosporin increased the AUC and C max of sitagliptin by approximately 29 % and 68 %, respectively. These changes in sitagliptin pharmacokinetics were not considered to be clinically meaningful. The renal clearance of sitagliptin was not meaningfully altered. Therefore, meaningful interactions would not be expected with other p-glycoprotein inhibitors. In vitro studies indicated that the primary enzyme responsible for the limited metabolism of sitagliptin is CYP3A4, with contribution from CYP2C8. In patients with normal renal function, metabolism, including via CYP3A4, plays only a small role in the clearance of sitagliptin. Metabolism may play a more significant role in the elimination of sitagliptin in the setting of severe renal insufficiency or ESRD. For this reason, it is possible that potent CYP3A4 inhibitors (i.e., ketoconazole, itraconazole, ritonavir, clarithromycin) could alter the phamacokinetics of sitagliptin in patients with severe renal insufficiency or ESRD. The effects of potent CYP3A4 inhibitors in the setting of renal insufficiency has not been assessed in a clinical study. In vitro transport studies showed that sitagliptin is a substrate for p-glycoprotein and OAT3. OAT3 mediated transport of sitagliptin was inhibited in vitro by probenecid, although the risk of clinically meaningful interactions is considered to be low. Concomitant administration of OAT3 inhibitors has not been evaluated in vivo. Effects of sitagliptin on other medicinal products: In vitro data suggest that sitagliptin does not inhibit nor induce CYP450 isoenzymes. In clinical studies, sitagliptin did not meaningfully alter the pharmacokinetics of metformin, glyburide, simvastatin, rosiglitazone, warfarin, or oral contraceptives, providing in vivo evidence of a low propensity for causing interactions with substrates of CYP3A4, CYP2C8, CYP2C9, and organic cationic transporter (OCT). Sitagliptin had a small effect on plasma digoxin concentrations, and may be a mild inhibitor of p-glycoprotein in vivo. Digoxin: Sitagliptin had a small effect on plasma digoxin concentrations. Following administration of 0.25 mg digoxin concomitantly with 100 mg of sitagliptin daily for 10 days, the plasma AUC of digoxin was increased on average by 11 %, and the plasma C max on average by 18 %. No dose adjustment of digoxin is recommended. However, patients at risk of digoxin toxicity should be monitored for this when sitagliptin and digoxin are administered concomitantly. Use in pregnancy and lactation: Janumet should not be used during pregnancy or breast-feeding. Effects on ability to drive and use machines: No studies on the effects on the ability to drive and use machines have been performed. However, when driving or operating machines, it should be taken into account that dizziness and somnolence have been reported. Patients should be alerted to the risk of hypoglycaemia when Janumet is used in combination with other sulfonylurea agents or with insulin. SIDE EFFECTS There have been no therapeutic clinical trials conducted with Janumet tablets however bioequivalence of Janumet with co-administered sitagliptin and metformin has been demonstrated. Sitagliptin and Metformin Adverse reactions considered as drug related reported in excess (> 0.2 % and difference > 1 patient) of placebo and in patients receiving sitagliptin in combination with metformin in double-blind studies are listed below. Frequencies are defined as: very common ( 1/10); common ( 1/100 to < 1/10); uncommon ( 1/1,000 to < 1/100); rare ( 1/10,000 to < 1/1,000); very rare (< 1/10,000). Sitagliptin with Metformin In a placebo-controlled 24-week study of sitagliptin 100 mg once daily added to ongoing metformin, the incidence of adverse reactions considered as drug-related in patients treated with sitagliptin added to ongoing metformin compared to treatment with placebo added to ongoing metformin was 9.3 % and 10.1 %, respectively. Investigations Uncommon: blood glucose decreased Nervous system disorders Uncommon: somnolence Gastrointestinal disorders Common: nausea Uncommon: upper abdominal pain, diarrhoea. In a 1-year study of sitagliptin 100 mg once daily added to ongoing metformin, the incidence of adverse reactions considered as drug-related in patients treated with sitagliptin added to ongoing metformin compared to sulphonylurea added to ongoing metformin was 14.5 % and 30.3 %, respectively. In pooled studies of up to 1 year in duration comparing sitagliptin added to ongoing metformin to a sulphonylurea agent added to ongoing metformin, adverse reactions considered as drug-related reported in patients treated with sitagliptin 100 mg occurring in excess (> 0.2 % and difference > 1 patient) of that in patients receiving the sulphonylurea agent are as follows: Metabolism and nutrition disorders Uncommon: anorexia Investigations Uncommon: weight decreased Sitagliptin with Metformin and a Sulphonlylurea In this 24-week placebo-controlled study of sitagliptin 100 mg once daily added to ongoing combination treatment with glimepiride and metformin, the overall incidence of adverse reactions considered as drug-related in patients treated with the addition of sitagliptin to the ongoing treatment with glimepiride and metformin was 18.1 % compared to treatment with the addition of placebo to the ongoing treatment with glimepiride and metformin which was 7.1 %. Gastrointestinal disorders Common: constipation Metabolism and nutrition disorders Very common: hypoglycaemia COMBINATION WITH A PPARγ AGENT (rosiglitazone) and METFORMIN In this study of sitagliptin 100 mg once daily in combination with rosiglitazone and metformin, which continued through 54 weeks, the incidence of adverse reactions considered as drug-related in patients treated with sitagliptin combination compared to treatment with the placebo combination was 15.3 % and 10.9 %, respectively. Other drug-related adverse reactions reported in the 54-week analysis (frequency common) in patients treated with sitagliptin combination occurring in excess (> 0.2 % and difference > 1 patient) of that in patients treated with the placebo combination were: headache, cough, vomiting, hypoglycaemia, fungal skin infection, and upper respiratory tract infection. Nervous system disorders Common: headache Metabolism and nutrition disorders Common: hypoglycaemia Gastrointestinal disorders Common: diarrhoea, vomiting General disorders Common: peripheral oedema Sitagliptin with Metformin and Insulin In this 24-week placebo-controlled study of sitagliptin 100 mg once daily as add-on to insulin and metformin, the incidence of adverse reactions considered as drug-related in patients treated with sitagliptin in combination with insulin/ metformin compared to treatment with placebo in combination with insulin/metformin was 16.2 % and 9.0 %, respectively. Nervous system disorders Uncommon: headache Gastrointestinal disorders Uncommon: dry mouth Metabolism and nutrition disorders Very common: hypoglycaemia. In a 24-week study of initial combination therapy with sitagliptin and metformin administered twice daily (sitagliptin/metformin 50 mg/500 mg or 50 mg/1,000 mg), the overall incidence of adverse reactions considered as drug-related in patients treated with the combination of sitagliptin and metformin compared to patients treated with placebo was 14.0 % and 9.7 %, respectively. The overall incidence of adverse reactions considered as drug-related in patients treated with the combination of sitagliptin and metformin was comparable to metformin alone (14.0 % each) and greater than sitagliptin alone (6.7 %), with the differences relative to sitagliptin alone primarily due to gastrointestinal adverse reactions. Additional information on the individual active substances of the fixed dose combination Sitagliptin In addition, in monotherapy studies of up to 24 weeks in duration of sitagliptin 100 mg once daily alone compared to placebo, adverse reactions considered as drug-related reported in patients treated with sitagliptin in excess (> 0.2 % and difference > 1 patient) of that in patients receiving placebo are headache, hypoglycaemia, constipation, and dizziness. In addition to the drug related adverse reactions described above, adverse events (reported regardless of causal relationship to medicinal product) occurring in at least 5 % and more commonly in patients treated with sitagliptin included upper respiratory tract infection and nasopharyngitis. Additional adverse events that occurred more frequently in patients treated with sitagliptin (not reaching the 5 % level, but occurring with an incidence of > 0.5 % higher with sitagliptin than that in the control group) included osteoarthritis and pain in extremity. Across clinical studies, a small increase in white blood cell (WBC) count was observed due to an increase in neutrophils. This observation was seen in most but not all studies. This change in laboratory parameters is not considered to be clinically relevant. No clinically meaningful changes in vital signs or in ECG (including in QTc interval) were observed with sitagliptin treatment. Post-marketing data Sitagliptin During post-marketing experience of Janumet or sitagliptin, one of the active substances of Janumet, the following additional adverse reactions have been reported (frequency not known): hypersensitivity reactions including anaphylaxis, angioedema, rash, urticaria, cutaneous vasculitis, and exfoliative skin conditions including Stevens-Johnson syndrome; pancreatitis. Metformin Nervous system disorders Common: metallic taste Gastrointestinal disorders Very common: gastrointestinal symptoms Skin and subcutaneous disorders Very rare: urticaria, erythema, pruritis Metabolism and nutrition disorders Very rare: lactic acidosis, vitamin B12 deficiency Hepatobiliary disorders Very rare: liver function disorders, hepatitis PACKAGE QUANTITIES Janumet 50mg/850mg and 50mg/1000mg film-coated tablets, 56 tablets. POM Date of preparation: Nov 2009 Marketing Authorisation numbers: Janumet 50mg/850mg film-coated tablets, EU/1/08/455/003. Janumet 50mg/1000mg film-coated tablets, EU/1/08/455/010. Marketing Authorisation Holder: Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, Hertfordshire EN11 9BU, UK. Merck Sharp & Dohme Limited All rights reserved. API.JANUMET.Nov09.IRL. References: 1. Data on file, MSD. 2. Goldstein BJ, Feinglos MN, Lunceford JK, et al; for the Sitagliptin 036 Study Group. Effect of initial combination with sitagliptin, a dipeptidyl peptidase-4 inhibitor, and metformin on glycemic control in patients with type 2 diabetes. Diabetes Care. 2007;30: Nauck MA, Meininger G, Sheng D, et al; for the Sitagliptin Study Group 024. Efficacy and safety of the dipeptidyl peptidase-4 inhibitor, sitagliptin, compared with the sulfonylurea, glipizide, in patients with type 2 diabetes inadequately controlled on metformin alone: a randomized, double-blind, non-inferiority trial. Diabetes Obes Metab. 2007;9: * SU = sulfonylurea; specifically glipizide. Additional prescribing information available on request or from Merck Sharp & Dohme Ireland (Human Health) Ltd. Pelham House, South County Business Park, Leopardstown, Dublin 18, Ireland JMT-2010-IRL-2927-J

5 Table 1. X-PERT Ireland Audit Results Note: Figures taken from data entered by May 27 th 2010 Baseline 6 Months 1 Year 2 Years HbA1c % 7.3 (n=1003) 6.8 (n=282) 7.0 (n=164) 7.0 (n=36) Weight kg 89.3 (n=1055) 85.2 (n=277) 86.1 (n=148) 85.8 BMI kg/m (n=1032) 30.8 (n=266) 30.3 (n=148) 30.0 Total Cholesterol 4.3 (n=1068) 4.2 (n=288) 4.0 (n=168) 3.8 (n=38) LDL Cholesterol 2.4 (n=975) 2.3 (n=255) 2.2 (n=157) 1.9 HDL Cholesterol (n=978) (n=254) (n=159) 1.1 (n=34) Triglycerides 1.7 (n=859) 1.6 (n=223) 1.5 (n=139) Not Available Systolic Blood Pressure mmhg (n=840) (n=239) (n=144) (n=21) Diastolic Blood Pressure mmhg 78.1 (n=839) 76.7 (n=239) 76.4 (n=144) 73.9 (n=21) Empowerment Score Not Available The programme has helped us meet our patients needs in an effective way by really involving them in organized proactive care plans. The patients now relate to the practice nurse on a more personal basis and we feel the condition of diabetes is much better understood and managed overall. The X-PERT programme is being successfully led out across Ireland by the community nutrition and dietetic services. Please contact your local community nutrition and dietetic department for further details. The healthcare cost of looking after people with diabetes is very high accounting for 5-15% of our health expenditure. References 1.Making Diabetes Count (2006). The Institute of Public Health in Ireland. 2.Diabetes Expert Advisory Group, HSE (2008). 3. NICE (2003). Guidance on the use of patient-education models for diabetes Health Technology Appraisal 60. London, National Institute of Clinical Excellence. 4.Department of Health and Diabetes UK (2005). Structured Patient Education in Diabetes Report from the Patient Education Working Group. London. 5.Harkins V (2008). A Practical Guide to Integrated Type 2 Diabetes Care. 6.Deakin TA, et al., (2006). Glycaemic Control: The Diabetes X-PERT Programme makes a Difference. Diabetic Medicine 23; O Brien YM et al., (2007). A structured patient-education programme for individuals with type 2 diabetes: The X-PERT Programme in Ireland. Proceedings of the Nutrition Society Vol 66 p74a 8. O Brien YM et al (2006). XPERT in Ireland a structured patient education programme for people with type 2 diabetes Diabetic Medicine, 23 (Suppl. 4), P446 pg NICE (2006). Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. 30