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Introduction:

This
report is an evaluation of an assessment done on the management of poor control
of type 2 diabetes, by a trainee pharmacist independent prescriber in a GP
surgery. During consultation, a history taking process involving patient’s
presenting complaint, medical and drug history, blood test results and diabetic
foot test were examined to reach a known diagnosis (type 2 diabetes). The signs
and symptoms of type 2 diabetes, exhibited by the patient are then critically
analysed and discussed to understand the pathophysiology of the condition.

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Diabetes
is a rapidly chronic condition that affects large number of people
worldwide,  causing increase in
morbidity, mortality and healthcare expenses (Hughes et al, 2017). It is a progressive disease that causes
hyperglycaemia (increase in blood sugar level) with disruption of carbohydrate,
fat, and protein metabolism (Shareef, Fernandes and Samaga, 2015). It is
estimated that more than 4 million in the UK will develop diabetes by 2025 (Bowron
et al, 2011).

The
clinical role of a pharmacist independent prescriber in a GP surgery involves
developing an effective understanding with patients, carers and other
prescribers, with the application of one’s clinical knowledge and skills, to
formulate a diagnosis and treatment plan. As part of the role, the
pathophysiology, signs and symptoms of the disease treated, needs to be fully
understood, and one should know how to take precise history and do relevant
clinical examination when required to treat a condition (General Pharmaceutical
Council (GPHC), 2016).

The
role of pharmacists has evolved considerably over the past three decades and
the focus has changed from product to patient orientation (Shareef, Fernandes
and Samaga, 2015). This has improved the management of diabetes with hospital
admission rates going considerably down and enhancing quality of life in
diabetic patients (Bowron et al, 2011). With increase in healthcare
demands and predicted shortages of GP’s and practice nurses in the near future,
it is important to manage chronic conditions such as diabetes on an ageing
population. In tackling patients early on, pharmacist independent prescribers
are in an ideal position to manage lifestyle factors that contribute to
diabetes, and potentially reverse the trend in line with the NHS five year
forward view (2017).

Medicine
compliance among patients with chronic conditions averages only 50% according
to World Health Organisation (WHO), costing the UK around  £500 million. Clinical pharmacists doing
medication review clinics have made an impact on non-compliance, thereby saving
NHS millions of pounds (Stone and Williams, 2015).

Moreover,
studies conducted so far have shown that patients have valued pharmacist
prescribing as an alternative to doctors in primary care. Practice pharmacist
can also reduce the burden on GPs by dealing with patient requests, repeat
prescriptions and queries along with booking appointments for essential blood tests
and for follow up to titrate the drug regimen, thereby allowing GP’s to
concentrate on other complex matters with regards to patients medical
conditions (Stone and Williams, 2015).

 

 

Known diagnosis: Type 2
diabetes.

Appendix
1 shows that the patient (A.M.) presents with symptoms of type 2 diabetes that
is not under control due to her high HbA1c levels.

Type
2 diabetes is a long term metabolic disorder that occurs due to decreased
insulin secretion by the pancreatic ? cells and insulin resistance, resulting
in hyperglycaemia (National Institute for Health and Care Excellence (NICE),
2015). The risk factors that increases the chances of developing type 2
diabetes are obesity, increasing age, ethnicity and family history (Kumar and Clark,
2017). Medical conditions such as hypertension, hyperlipidemia, central obesity
can give rise to or worsen type 2 diabetes (Olokoba, Obateru and Olokoba, 2012).

90%
of all cases of diabetes mellitus are due to type 2 diabetes. It is prominently
seen in developing as compared to developed countries (69% vs. 20%) (Ozougwu, et al,
2013). Around 850,000 people in the UK, are presently living with undiagnosed
type 2 diabetes. Estimated 50% of patients have shown evidence of complications
at the time of diagnosis (Langran et al,
2017). Type 2 diabetes is profoundly seen in African, African-Caribbean and
South Asian family origin. It can happen in any age groups and children are
being increasingly diagnosed with type 2 diabetes (NICE, 2015).

Lifestyle
factors and genetics are the main causes of type 2 diabetes. Lifestyle choices
such as decreased physical activity, cigarette smoking, increased consumption
of alcohol, and sedentary lifestyle play an important role in type 2 diabetes
(Olokoba, Obateru and Olokoba, 2012). Obesity is a growing concern in the UK
and people who are obese are 80 times more in danger of developing type 2
diabetes than normal healthy adults (Bowron et
al, 2011).

In
type 2 diabetes, insulin resistance and reduced insulin production in the
patient (A.M.) leads to decrease transport of glucose in to the liver, muscle
and fat cells. The breakdown of fat increases with hyperglycaemia. As a result
of this dysfunction, the increased levels of glucagon and hepatic glucose
produced during fasting, fail to appropriately suppress with a meal which in
turn causes hyperglycaemia. The incretins Gastric inhibitory polypeptide (GIP)
and Glucagon-like peptide (GLP-1) that stimulate insulin production after
eating, is also impaired in type 2 diabetic patients. The adipose tissue
through the secretion of adipocytokines has also been shown  to play a role in insulin resistance and  ? cell dysfunction (Olokoba, Obateru and
Olokoba, 2012).

 

Acquisition and Critical Evaluation of Key Clinical
Findings:

Calgary-Cambridge
model was used during the consultation process. There are 5 main steps in this
consultation (Centre For Pharmacy Postgraduate Education (CPPE), 2014) as shown
in appendix 1 .

By
listening and allowing patients to share their views during consultation,
practice prescribers are in a better position to instil confidence in patients
and hence improving their adherence to medicines and overall treatment .This
model was used exclusively because the patient (A.M.) had limited information
about type 2 diabetes. In order to establish an understanding, trust and build
confidence in her, such an approach was used so that she fully understands the
condition and complies with the treatment (Kaufman, 2008).

 

A.M. came
in to see her GP for a diabetic review. On enquiry, she complained of suffering
from the following symptoms – Frequent
urination (polyuria) which is
affecting her sleep at night, fatigue,
genital itching, persistent dry mouth and decreased sensation (neuropathy) in her
feet. These symptoms are indicative of type 2 diabetes (Clark,
Fox and Grandy, 2007). She is taking anti-diabetic medications as shown in
appendix 1 (Kumar and Clark, 2017). HbA1c
which refers to glycated haemoglobin is used as a diagnostic test for diabetes
(Vijayakumar et al, 2017). A.M. has a
HbA1c of 112mmol/mol which demonstrates that her blood sugar levels
are not under control (NICE, 2015)

A) A.M.
is experiencing frequent urination
(polyuria) which is a classic symptom of poor control of type 2 diabetes (Chasens
et al, 2002). Polyuria is a condition
whereby a body urinates excessive and unusual large amounts of urine. It is
normally 3 litres a day where as a healthy adult excretes about one to two
litres (Diabetes.co.uk, 2017). The prevalence of diseases among the population,
causing polyuria are as follows (Jakes and Bhandari, 2013):

Common
(>1 in 10) – Diabetes mellitus, Diuretics/caffeine/alcohol, Lithium, Heart
failure.Infrequent
(1 in 100) – Hypercalcaemia, Hyperthyroidism.Rare
(1 in 1000) – Chronic renal failure, Primary polydipsia, Hypokalaemia.Very
rare (<1 in 10,000) - Diabetes insipidus. There are 4 mechanisms by which polyuria occurs. One or more of these will be functioning (Sarma, 2013). Increased consumption of fluids such as in stress and anxiety.Increased Glomerular Filtration Rate (GFR) that is seen in hyperthyroidism, fever.Increased volume of solutes - which occurs in diabetes mellitus, hyperthyroidism, hyperparathyroidism.Failure of the kidney to reabsorb water in Distal Convoluted Tubule (DCT) - such as in central diabetes insipidus, nephrogenic diabetes insipidus, chronic renal failure.   The cause of frequent urination in A.M. is due to osmotic diuresis which occurs when blood sugar levels goes beyond renal threshold (?180 mg/dL). This results in excretion of excess glucose via kidneys in urine. Water then follows glucose excreted in urine leading to high urine output (Chasens et al, 2002). It is essential to keep a voiding diary, that tracks the measurements of voiding volumes so as to make a diagnosis  (Kujubu, 2009). In the United Kingdom, more than 1 in 20 people are affected by diabetes mellitus and is the most prevalent cause of polyuria is adults and children (Jakes and Bhandari, 2013). Symptom of high blood sugar level including polyuria, are not always noticeable in children and cannot be relied on to determine those with type 2 diabetes. Therefore it is important to monitor children who are at high risk, even if symptoms are absent (Sawatsky, Halipchuk and Wicklow, 2017).   B) Fatigue is a frequent and worrying complaint among patients with diabetes. In diabetes, it may be related with physiological occurrence such as hypo- or hyperglycaemia (Jain et al, 2015). The poor management of type 2 diabetes along with obesity (A.M. has a BMI of 32kg/m2 ) and a lack of physical activity has contributed to excessive levels of fatigue in the patient (Fritschi and Quinn, 2010). It has been defined as 'personal understanding of a reduced capacity to perform physical and/or mental activity that is caused by one or a combination of physiological, psychological or lifestyle factors, including change in glucose control, symptoms of diabetes, depression, physical inactivity and body mass index ' (Park et al, 2015). Although arguable, fatigue in diabetes can be identified and measured by scales such as Fatigue Severity Scale (FSS), Fatigue Assessment Scale (FAS) and Visual Analog Fatigue Scale (VAFS) (Singh and Kluding, 2013) In women with type 2 diabetes, fatigue was found to interfere with self reported quality of life than their healthier counterparts (Fritschi and Quinn, 2010). Further investigation is required to study fatigue and its causing factors, for adequate management of diabetes (Singh and Kluding, 2013).   C) Genital itching is also one of the symptoms that A.M. complained of, and is common in patients with type 2 diabetes (National Health Service (NHS).uk, 2017). This symptom occurs when blood glucose levels are high, leading sugar to be excreted in urine. Glucose creates a fertile breeding area for bacteria which grows around the genitals and causes itching (Geerlings et al, 2014). Type 2 diabetes mellitus can lead to growing risks of asymptomatic bacteria, urinary tract infections (UTI'S) and non- sexually transmitted genital infections (vulvovaginal infections and balanitis) (Geerlings et al, 2014). The actual mechanism is not known, but increase in blood sugar levels has been shown to damage various immune systems including neutrophil operation and antibody function (Hine et al, 2016). The symptoms of UTI in diabetics resemble those reported in healthy patients. However, there is an increased risk of acute upper UTI (pyelonephritis) in diabetes, requiring hospital admission (Geerlings et al, 2014). With regards to fungal infection, the most common organism was candida glabrata followed by candida albicans in the vaginal swabs of diabetic patients where as C. albicans was profoundly found in non- diabetics (Goswami et al, 2006).   D) Diabetes mellitus is associated with a number of oral health problems (Al-Maweri et al, 2013). During the examination, it was noted that A.M. was suffering from dry mouth (xerostomia), another feature of poor control of type 2 diabetes (Lopez-Pintor et al, 2016). Damage of salivary gland  in type 2 diabetes can affect the quality and quantity of saliva (Aitken-Saavedra et al, 2015). The cause of dry mouth in A.M. could be attributed to the impairment of the gland parenchyma, modification of salivary gland microcirculation, dehydration and disruption of blood glucose levels (Lopez-Pintor et al, 2016). The physical, chemical and biological properties of saliva protects the tissues in the mouth and helps in speech production, food chewing, food tasting and digestion. A reduction in salivary production or altering in its quality can result in poor health related quality of life and can cause oral lesions such as caries, angular cheilitis, periodontal disease and candidiasis (Aitken-Saavedrav et al, 2015). It is important for healthcare professionals to understand the various conditions in which diabetes mellitus can exhibit orally, so that there is prompt management and treatment as wells as measures taken to control high blood sugar levels (Bajaj et al, 2012). A variety of  treatment options are available for xerostomia depending on the cause. These include regular sipping of water and use of various types of sprays and gels (Dyasnoor, Kamath and Khader, 2017).   E) With reference to appendix 1, A.M. was found to have decreased sensation on both feet due to increased levels of sugar in the body. Neuropathy is one of the most frequent microvascular complications of diabetes (Kasim et al, 2010). It is a degenerative disease of the peripheral nerve, that results in symptoms of pain or paresthesia (burning or pricking sensation in the hands, arm or feet) or a complication arising from neurological shortfall (Boru et al, 2004). Diabetic neuropathy roughly affects around 50% of patients suffering from diabetes mellitus and is associated with serious rise in morbidity and mortality (Cancelliere, 2016). The cause of neuropathy in A.M. is due to the accumulation of sugar (sorbitol and fructose) in schwann cells which may damage the function and structure of nerves. There is a delayed nerve conduction velocity as a result of functional change. The damage to the schwann cells results in change in segmental demyelination as the first histological change. Axons are protected in the early stages, suggesting the possibility of recovery where as at a later stage, irreversible degeneration of axon occurs (Kumar and Clark, 2017). There are four main pathways by which hyperglycaemia gives rise to peripheral neuropathy (Cancelliere, 2016): (i) Polyol pathway - The polyol works by acting on the enzyme aldose reductase. When blood glucose level increases, the enzyme aldose reductase reduces glucose to sorbitol which is then oxidized to fructose. Nicotinic adenine dinucleotide phosphate (NADPH) is consumed as a result of this process. NADPH are involved in generating glutathione which in turn plays an important role in lowering intracellular oxidative stress. (ii) Overproduction of advanced glycation end products (AGEs) - AGEs precursors can damage cells by: a) altering intracellular proteins that are involved in gene transcription regulation. b) extracellular components modified by AGE precursors alter the communication between the matrix and the cells and results in cellular dysfunction. c) The AGEs alter the circulating proteins and activate the AGEs receptors, that produces inflammatory cytokines and growth factors, resulting in tissue and cellular damage. (iii) Protein Kinase C activation - Hyperglycaemia increases the release of diacylglycerol which activates protein kinase C cofactors. Protein kinase C exerts it's  effect on gene expression including decrease sensitivity of endothelial nitric oxide (NO) and increased response of vasoconstrictor endothelin-1. This leads to alteration in Schwann cell metabolism and finally axonal flow. (iv) Hexosamine pathway flux - when blood glucose level increases intracellularly, glucose is broken down through glycolysis, with the resulting fructose-6 phosphate diverted in to the signalling pathway. The enzyme glutamine fructose-6 phosphate amidotransferase (GFAT) then changes fructose-6 phosphate to UDP (uridine phosphate) N-acetyl glucosamine. This attaches to serine and threonine, leading to alteration in gene expression. Peripheral neuropathy can appear as a loss of sensation, which can generate neuropathic ulcers, and is a common cause of amputation (Davies et al, 2006). The frequency of peripheral neuropathy is generally related with high blood pressure, cigarette smoking and hyperlipidemia (Kasim et al, 2010). Patients who are type 2 diabetic should be screened for peripheral neuropathy at initial diagnosis and at least annually by investigating sensory function in the feet and examining ankle reflexes. Sensory function can be assessed by one or more of the following -  vibration test (using a tuning fork), temperature, pinpricking of the feet or pressure feeling (Boulton et al, 2005). The following drugs are recommended for treatment of neuropathic pain including diabetic neuropathy - amitriptyline (off-label), duloxetine, gabapentin or pregabalin. The prescribing of more than one neuropathic pain drug at the same time is not recommended. Capsaicin 0.075% cream can be considered for those who have localized neuropathic pain and who wish to avoid or cannot tolerate oral drugs (Clinical Knowledge Summaries (CKS).nice.org.uk, 2017).   Reflection: An advanced health assessment was done on a patient (A.M.) exhibiting symptoms of poor control of type 2 diabetes. This was based on patients complaints about symptoms that she experienced, drug and medical history. Since this was the first time I was conducting a consultation, I felt nervous and excited, trying to make sure that all the required questions and tests are done in order to understand the patient's signs and symptoms. There was an element of doubt in patient's mind about her HbA1c levels. I felt that I was able to explain to her properly what HbA1c signifies in terms of her high blood sugar levels in the body. Despite this, the time to manage the consultation took longer than allocated. As shown in appendix 1, A.M. has a HbA1C of 112mmol/mol (18.3mmol/l). If the levels continue to be over 11mmol/l, it can be a contributing factor to Diabetic Ketoacidosis (DKA) (Savage et al, 2011). DKA is a life threatening condition that commonly occurs in type 1 diabetes, but is now increasingly seen in patients with type 2 diabetes (Misra, Oliver and Dornhorst, 2013). A blood ketone test could have been done for A.M. to confirm  the presence or absence of DKA. Self monitoring of blood glucose at home would be beneficial for A.M., so as to measure blood glucose levels regularly and report the readings to doctor if it carries on to remain high. Since patients with type 2 diabetes are prone to urinary tract infections (UTI)  (Geerlings et al, 2014), a urine culture test was done to rule out any incidences of lower UTI  in A.M. (Barger and Woolner, 1995). A physical examination involving palpation of the suprapubic area for tenderness and checking for exclusion of costovertebral angle tenderness (CVAT), could have been done to exclude symptoms of cystitis in A.M. Further tests involving abdominal and pelvic bimanual palpation for pain and tenderness and a speculum assessment is ideal to eliminate incidences of upper genital tract infection (Barger and Woolner, 1995). Palpating bladder  is another examination that could have done for A.M. to determine the degree of incontinence (Barger and Woolner, 1995). The knowledge I have gained in this health assessment will enable me to tackle different symptoms arising from type 2 diabetes. I have learnt that type 2 diabetes is a complex condition that sometimes requires further investigation to exclude potential complications.                     Conclusion: Type 2 diabetes is the most common type of diabetes that causes hyperglycaemia due to decreased pancreatic insulin production and insulin resistance (Olokoba, Obateru and Olokoba, 2012). Its prevalence is considerably greater in developing than in developed countries (Ozougwu et al, 2013). It is characterised by symptoms such as frequent urination, increased thirst, uncommon weight loss and fatigue (Clark, Fox and Grandy, 2007). Long lasting complications of type 2 diabetes include retinopathy, nephropathy, peripheral neuropathy and autonomic neuropathy that can result in gastrointestinal, genitourinary, cardiovascular and sexual dysfunction. (Diagnosis and Classification of Diabetes Mellitus, 2010). It can be prevented through lifestyle changes, control of diet, overweight and obesity (Olokoba, Obateru and Olokoba, 2012).                  

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