February 2016 DIABETES PHARMACY TEAMS MAKE A DIFFERENCE. Why am I here? Why are you here? Identifying people at risk. What can we do?

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1 DIABETES PHARMACY TEAMS MAKE A DIFFERENCE Sallianne Kavanagh MRPharmS, MSc, IP Lead Pharmacist Diabetes and Endocrinology Sheffield Teaching Hospitals UKCPA Joint Chair Diabetes and Endocrinology Why am I here? Why are you here? Currently 3.9 people in the UK are living with Diabetes 6, undiagnosed 7 people are diagnosed each day UK prevalence 6.2% of adults 1 in 16 people In Bradford Bradford District CCG- 22,974 people with Diabetes ( 9% prevalence) Bradford City CCG- 6,417 people with diabetes ( 11% prevalence) Highest in England! When I meet the patient its often too late! Community Pharmacy teams are the face of pharmacy- the place for real differences to be made What can we do? Identify people at risk Listen to our patients Make every contact count- ask questions, listen to the answers Know about the medications Apply our knowledge to what we hear from the patient- Make the difference Identifying people at risk The Diabetes Risk Score An assessment tool which aims to identify individuals with impaired glucose regulation (IGR) Designed to predict an individual s risk of developing Type 2 diabetes within the next ten years It was developed by University of Leicester and University Hospitals of Leicester NHS Trust in collaboration with Diabetes UK The 212 NICE public health guidance Preventing type 2 diabetes: risk identification and interventions for individuals at high risk, recommended that GPs and other primary healthcare professionals use the tool for identifying people at risk of developing Type 2 diabetes Service providers including pharmacists, managers of local health and community services and voluntary organisations, employers and leaders of faith groups should offer validated self-assessment questionnaires or validated webbased tools (for examples, see the Diabetes UK website) They should also provide the information needed to complete and interpret them Identifying people at risk The Diabetes Risk Score is intended for you to use free of charge if you intend to use it as A healthcare professional in the NHS or private healthcare A healthcare professional in an NHS pharmacy, independent pharmacy, or group pharmacy of 2 branches or fewer A student or lecturer in an educational institute. Complete a Diabetes Risk Score enquiry form The Diabetes Risk Score may not be free of charge if you intend to use it in Non-NHS workplace occupational health A group pharmacy of more than 2 branches The fitness industry A commercial setting And/or Intend to make monetary gain. Complete a Diabetes Risk Score Partnerships enquiry form Identifying risk How old are you? A 49 or younger [] B 5 59 [5] C 6 69 [9] D 7 or older [13] Are you female or male? A Female [] B Male [1] What is your ethnic background? A Only white European [] B Other ethnic group [6] Do you have a father, mother, brother, sister and/or own child with Type 1 or Type 2 diabetes? A Yes [5] B No [] Measure the person s waist circumference and choose the range: A Less than 9cm (35.3in) [] B cm ( in)[ 4] C cm ( in) [6] D 11cm (43in) or above [9] Calculate the person s Body Mass Index (BMI) and choose the range (a BMI chart can be used). A Less than 25 [] B [3] C [5] D 35 or above [8] Have you been given medicine for high blood pressure OR told that you have high blood pressure, by your doctor? A No () B Yes (5) 1

2 Identifying my risk How old are you? 21 of course- 36- nil points Are you Female or Male? Female nil points What is your Ethnic Background? white only- nil points Do you have a 1 st degree relative with Diabetes? no nil points What is your waist circumference? Teeny weeny? Less than 35 inches nil points BMI? Below 25 nil points Hypertension? nope! Nil points Thankfully I have nil points- so I am low risk Your average male customer? Age- old 9 points Male 1 point White points Relative with DM? No? points Waist : 4+ inches- 6 points BMI above 25 = at least! 3 points High BP- Yes- surely!!! 5 points 24 points-moderate risk- see his GP Any DM in his family? High risk 1 in 3 chance A Healthy Chat You have correctly identified that Mr Trump is at risk of diabetes What next? Leave him to it? Talk to him about reducing his risk Staff/Individual asks a lifestyle question Staff responds to lifestyle issue Individual is unsure if they want to change Individual wants to make a change Individual does not want to make a change Agree an action A visit to the GP Diagnosis of Type 2 Diabetes Diet and exercise advised UKPDS- UK prospective diabetes study Better glycaemic control fewer complications 1% reduction makes a difference! 43% reduction in PVD 14% reduction in heart attacks Started on treatment Legacy effect of early treatment Reduction in diabetes complications and deaths People still die- but not from diabetes New NICE guidance What should he be started on? Chat about taking medication How will he fit this in to his life? Possible barriers Provide information- especially on side effects that could limit continued adherence Importance of early treatment and achievement Aggregate endpoint Legacy of early treatment Any diabetes related endpoint Legacy effect Relative risk reduction % 9% Microvascular Disease 25% 24% Myocardial infarction 16% 15% All cause mortality 6% 13% NICE: Managing blood glucose in adults Individualised targets Drug treatment started Drug treatment started Initial treatment if C/I or not tolerated Consider one of the following: - a DPP-4i, pioglitazone or an SU 1 st Intensification 1 st Intensification 2 nd intensification Insulin based treatment - metformin and a DPP-4i - metformin and pioglitazone - metformin and an SU - metformin and an SGLT-2 a DPP-4i and pioglitazone - a DPP-4i and an SU - pioglitazone and an SU Insulin based treatment triple therapy with metformin, a DPP-4i and an SU metformin, pioglitazone and an SU o metformin, pioglitazone or an SU, and an SGLT-2iinsulin-based treatment Insulin based treatment Consider insulin based treatment 2

3 Diabetes Treatment Glucotrol (Glipizide) Rezulin (Troglitazone) Actos (Pioglitazone) Avandia (Rosiglitazone) Avandamet (Rosiglitazone + (generic) Januvia (Sitagliptin) Onglyza (Saxagliptin) Tradjenta (Linagliptin) Bydureon (Exenatide M/R) Jardiance (Empagliflozin) Invokana (Canagliflozin) Vipidia (Alogliptin) Glucoghage () Precose (Acarbose) Amaryl (Glimepiride) Prandin (Repaglinide) Glucovance (Glyburide + ) Starlix (Nateglinide) Symlin (pramlintide) Byetta (Exenatide) Actosplus Met (Pio + Met) Janumet (Sitagliptin + Met) Victoza (Liraglutide) Galvus (Vildagliptin) Forxiga (Dapagliflozin) Trulicity (dulaglutide) Therapy options The single best drug! Acts only in the presence of insulin Decreases gluconeogenesis and increases insulin-mediated peripheral utilisation of glucose Expected HbA1c reduction.8 2.% (9-22mmol/mol) Simple dosing- best max dose is 2g Does not cause hypoglycaemia alone, but potentiates hypo when used with other agents that can cause hypos) Weight Neutral Hence used first line in patients with type 2 diabetes who are overweight Little side effects apart from GI disturbances Incidence minimised by starting with a low dose (5mg od), taking with food and titrating slowly Modified-release preparation may help Take with meals UKPDS 34 - Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (1998) Showed reduction in diabetes-related end points (including death) of overweight people with diabetes Caution in renal impairment Avoid in egfr <3ml/min, AKI, acute heart failure Lactic acidosis - risk review Lactic acidosis A rare, but potentially fatal, side-effect 1-5 cases per 1 population, but it has a reported mortality of 3-5% Occurs because metformin reduces hepatic uptake of lactate Risk reduced by avoiding metformin use in patients with: renal impairment (Cr > 15 μmol/l or egfr < 3mL/min/1.72m²) Should review if (Cr > 13 μmol/l or egfr < 45mL/min/1.72m²) a risk of tissue hypoxia (sepsis, severe heart failure or significant hepatic impairment) patients receiving iodinated contrast media AKI Action Point!- patients who are acutely ill- stop metformin See the GP, speak to the diabetes team Advise when they come for acute problem, dehydrated etc Diabetes becomes more complicated over time Disease progression At Diagnosis Treatment reviews- MURs and daily contacts Diet & Exercise Elderly patients Individualised treatment plans Complications Complication De-prescribing Polypharmacy prevention issues STOPP/START Management of Intense therapy to Adherence reviews Review of targetssofter targets complications reach targets Development of Polypharmacy complications Risk Vs benefit QOL review Review of targets 3

4 UKPDS: Glycemic control worsens over time Polypharmacy Vs HbA1c 9 Monotherapy with insulin, sulphonylurea (SU) or metformin Median HbA 1c (%) Years from randomisation Conventional (n=2) Chlorpropamide (n=129) Glibenclamide (n=149) (n=181) Insulin (n=199) UKPDS Group. Lancet 1998;352: Sulphonylureas Gliclazide (Diamicron ), glipizide (Minidiab ), glimepiride (Amaryl ), Tolbutamide Stimulate insulin release by the beta cells of the pancreas insulin secretagogues Require functioning beta cells to work Prolonged diabetes more beta cell loss Effective for rapid control of osmotic symptoms Good if need quick action Dose has an immediate impact on blood glucose for duration of drug action T1/2 Expected HbA1c reduction 1 2% (11-22mmol/mol) Need to be taken with meals to prevent hypoglycaemia Risk of accumulation and hypos in renal impairment (and therefore the elderly) Avoid long-acting SUs in elderly/frail Hypos and weight gain Meglitinides Repaglinide (Prandin ) & Nateglinide (Starlix ) Stimulate insulin secretion but only in the presence of food insulin secretagogues Rapid onset and short duration of action than sulfonylureas Useful for people with varied CHO intake Useful for people with erratic lifestyle Lower risk of hypoglycaemia compared to sulfonylureas Match to CHO intake Pioglitazone Pioglitazone (Actos ) Rosiglitazone withdrawn 21 due to CV safety concerns PPAR gamma agonists (nuclear receptor) Switched receptors on to respond to insulin Enhances tissue sensitivity to insulin Contraindications/ adverse effects: heart failure hepatic impairment bladder cancer Osteoporosis Generally 3 rd line when suboptimally controlled on metformin and SU, due to sideeffects Expected HbA1c reduction.6-1.5% (7-17mmol/mol) Oedema, weight gain, fractures Careful use with insulin- increased HF risk Incretin Effect 4

5 DPP-4 inhibitors the gliptins Sitagliptin, saxagliptin, vildagliptin, linagliptide, alogliptin Generally well-tolerated Slow the degradation of endogenous circulating incretin hormones- raise levels 2-3 fold Once-daily Can be used in renal impairment with dose adjustments, where metformin is not an option Some require dose adjustment Linagliptin no dose adjustment needed in any degrees of renal dysfunction HbA1c reduction.5 1%, good for small goals NICE- only continue treatment if HbA 1c reduction.5% Sitagliptin & Vildagliptin can be used as dual therapy with Mt or SU Sitagliptin can be used in triple therapy No hypos, no weight gain Incretin effect after oral glucose is diminished in type 2 diabetes Venous plasma glucose (mmol/l) insulin (mu/l) Adapted from Nauck M, et al. Diabetologia 1986;29: Oral/Intravenous glucose infusion study Healthy controls (n=8) Normal incretin effect insulin (mu/l) Time (minutes) Venous plasma glucose (mmol/l) Type 2 diabetes (n=14) Diminished incretin effect Time (minutes) Oral glucose intravenous glucose Isoglycaemic p.5 vs. respective value after oral load; IR=immunoreactive. TR-2 GLP1s SGLT2s Exenatide, liraglutide, lixisenatide, dulaglutide Weight loss (1-4 kg) slow gastric emptying owing to central effects on satiety Nausea, vomiting, diarrhoea Pancreatitis HbA1c reduction.8 1.5% Injection is a barrier Once weekly injection available Combination with insulin to achieve target, less hypos compared to prandial insulin NICE criteria SGLT2 Insulin independent mechanism of action Can be used as add on therapy to other glucose lowering agents To be used in same situation where you could have previously considered DPP-4s Not Mt + SU combination May be used with insulin +/- other OHGs Can be used as a single agent if intolerant of metformin Inhibition of SGLT2 urinary excretion of 7g glucose a day HbA 1c reductions 1 % Weight loss a positive consequence not licensed for this Efficacy dependent on renal function Side effects UTIs Hypotension Dehydration- careful use with renal impairment Recent reports of euglycaemic DKA Happening at a much lower plasma glucose level (< 13.9mmol/L) Pancreatitis/pancreatic surgery Bone fractures Sugar content Product Sugar content- grams Sugar content (tea spoons) Soft drinks 6ml bottle /4 Sports drinks (powerade) /2 Soft drink 375ml can 41 1 Sports drink (gatorade) 6ml 36 9 Full fat flavoured milk 28 7 Orange juice 2 5 A cup of tea 8 2 A days lot of brews 8 2 5

6 Sugar content Snack Sugar (g) tsp Bounty 2 Bar Pack 57.8g 8.23 tsp (32.9g) Chrunchie 61.7g 6.18 tsp (24.7g) Kit Kat 47.8g.75 tsp (3g per two finger) Product Amount per 1g Sugar Content in Teaspoons Mars Bar 68.1g 1.7 tsp (42.6g per bar) Milk Chocolate 52.8g Milky Way 2 Bar Pack 72.4g 7.93 tsp (31.7g) Pepper Mints Plain Chocolate 56.8g 46.8g 2.2 tsp (8.8g per three squares) 1.2 tsp (4.8g per sweet) 1.95 tsp (7.8g per three squares) Empagliflozin news! EMPA-REG Trial demonstrated benefit on survival regardless of the cause of death Significant 38% RRR in CV mortality and 32% RRR in all-cause mortality Did not affect the rate of non-fatal MI/stroke, but fewer deaths after MI, sudden deaths and of unknown cause 35% relative reduction in hospitalisation for heart failure Class effect? Beneficial to middle-aged with type 2 diabetes at risk of CV events? Snickers Bar 54.5g 7.9 tsp (31.6g) Toffees 37.4g.78 tsp (3.1g per sweet) Twix 2 Bar Pack 64.5g 9.5 tsp (38g) Next steps What are they taking currently? Check adherence Failed strategies know what has been tried BMI, renal function What are patient s priorities? Fear of hypos, weight gain, injections Every patient is an individual! Extra resources Diabetes UK Diabetes in healthcare How to recognise the symptoms of diabetes, and how it can be diagnosed How to treat diabetes through lifestyle and medication and what to do if not under control How diabetes is monitored, both by healthcare professionals and by the patient How to recognise people at risk of complications associated with diabetes, and how to support them to reduce these risks How diabetes affects patients' lives, and how to support the patient emotionally throughout their diagnosis and treatment How to encourage self-management and structured education Healthcare/ NICE Type 1 elearning package 6