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Using diabetes tools to manage your patients

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By Mike Boivin BSc.Phm.

Patient education is a key component of pharmacy practice. Pharmacists are not only expected to provide information on medications, but increasingly asked more detailed information on the disease and its overall management. Educating a patient not only helps to improve outcomes, but can create the strong patient relationships that build loyalty and grow the pharmacy business.

Pharmacists are expected to provide information on many conditions, but it can be very difficult to provide the real-time information patients require. Fortunately, there are excellent tools that can facilitate disease management and improve the care pharmacists offer.  

This article will focus on diabetes management tools. The tools provided can be used by every pharmacist and not just those who are certified diabetes educators (CDE). These tools can help educate and improve the outcomes of this highly prevalent condition.  

 

1. FIT Forum for Injection Technique

(http://www.fit4diabetes.com/canada-english/)

This tool is a detailed reference on the administration of insulin and proper injection technique. It also includes recommendations on needle length selection, insulin storage, and site rotation. The FIT Technique Plus is a series of patient information to help counsel patients.  
2. Just the Basics and Beyond the Basics

Just the Basics – (http://guidelines.diabetes.ca/cdacpg/media/documents/patient-resources/just-the-basics-healthy-eating.pdf)
Beyond the Basics – (http://www.diabetes.ca/clinical-practice-education/professional-resources/diet-nutrition-beyond-the-basics)

Some of the most commonly asked questions regarding diabetes are related to food.

The Just the Basics tool has some basic dietary information that can be easily integrated into counselling patients with diabetes. The portion size tool is a great teaching aid to help patients better manage their diet.

The Beyond the Basics tool provides information regarding how to tailor diet choices for patients. This tool can help a patient select a wide variety of foods with a predictable effect on blood sugar levels. The ‘helpful hints for educator document’ provides pharmacists with some easy diet recommendations that can be integrated into counselling patients with diabetes.

 

3. ABCDEs of Vascular Protection

ABCDEs – (http://guidelines.diabetes.ca/vascularprotection/abcdes)
Drugs for Vascular Protection – (http://guidelines.diabetes.ca/cdacpg_resources/Reference_Guide-Vascular_protective_medications.pdf)

Managing a patient with diabetes is not just about blood glucose control. Most patients with diabetes will die from cardiovascular disease. The Diabetes Canada guidelines provide clear recommendations on strategies that can reduce the patient’s cardiovascular risk. These include managing:

  • A1C
  • Blood Pressure
  • Cholesterol
  • Drugs for vascular protection
  • Exercise/eating
  • Smoking cessation

Pharmacists should consider integrating the ABCDEs into counselling patients with diabetes. Monitoring a patient’s ABCDEs and ensuring patients are taking the medication for vascular protection can also create opportunities for pharmacist services such as pharmaceutical opinions, care plans and adaptation.  

 

4. SMBG Testing Guidelines

Self-Monitoring of Blood Glucose (SMBG) Recommendation Tool for Healthcare Providers (http://guidelines.diabetes.ca/cdacpg_resources/SMBG_HCP_Tool_lc_final.pdf)

With limits being placed on the number of testing strips by many payers, pharmacists should ensure their patients are testing appropriately based on their current regimen.  Diabetes Canada has developed clear recommendations for SMBG testing. They also provide recommendations on when to increase SMBG testing frequency. This tool also provides pharmacists with guidance on how to adjust insulin therapy based on the different SMBG readings.

By integrating these recommendations into meter training, pharmacists can ensure patients are testing appropriately.  

 

5. Carbs & Cals

(http://www.carbsandcals.com/)

Carbs & Cals has a book and app that can help patients with diabetes select food. The extensive database provides pictures of different portion sizes of many types of food. For each food choice and portion, the app provides the calories, fat, carbohydrates, protein and fibre. This can help patients who are carbohydrate counting, but also help them make food choices that can lead to weight loss. The app costs under $10 at both the Apple App and Google Play stores.  


Dealing with problems that are more than skin deep

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By Shelley Diamond, BScPhm

 

The skin offers a window to what is happening inside the body, so changes to the skin may signal a more serious health problem, often serving as a marker for underlying internal disease. For those living with diabetes, hyperglycemia affects skin homeostasis. Skin disorders may appear during the course of the disease or often may be the first sign of the condition.

 

How common are skin disorders in people with diabetes?

 

Skin disorders occur more commonly in those with type 2 diabetes, however overall prevalence has ranged from approximately 51 to 97 per cent of patients. The most frequent disorder is infection, which occurs in approximately 20 per cent of diagnosed patients.

 

What types of cutaneous manifestations occur?

 

The cutaneous presentations can be divided into four categories, including:

 

  1. Skin lesions (presenting features described in the following section)
  2. Infections (bacterial – usually Staphylococcus resulting in styes, boils, folliculitis, carbuncles, nail infections; fungal – usually Candida albicans causing jock itch, athlete’s foot, ringworm and vaginal infections)
  3. Cutaneous manifestations of other diabetes complications (microangiopathy, macroangiopathy, neuropathy)
  4. Skin reactions to diabetes medications (sulphonylureas or insulin)

 

What are the presenting features of diabetes-related skin disorders?

 

People with diabetes may present initially with xerosis, or calluses and fissures.

 

Among other diabetes-related lesions:

 

  • Necrobiosis lipoidica diabeticorum (begins as small raised solid bumps that evolve into patches of swollen, hard skin which are yellowish, reddish or brown in colour; usually on the lower parts of the legs; may be itchy and painful)
  • Acanthosis nigricans (appears as a dark patch of velvety skin on the back of the neck, armpit, groin; often the first sign that someone has diabetes or a sign of prediabetes)
  • Digital sclerosis (develops as tight, waxy skin on the fingers, toes, arms, back, shoulders, neck, knees, ankles, or elbows, and may result in mobility issues)
  • Bullosis diabetricorum/diabetic bullae (blisters which resemble burn blisters but are not painful)
  • Diabetic ulcers (note: these require immediate attention; those with a diameter of cellulitis greater than or equal to 2 cm at the largest area with signs of serious ischemia, systemic toxicity and bone and/or joint involvement are considered ‘limb-threatening’)
  • Diabetic dermopathy (brown spots or lines usually appearing on the shins, also known as ‘shin spots’)
  • Xanthelasma (yellowish scaly patches on and around the eyelids)
  • Eruptive xanthomatosus (tender, itchy bumps that become yellowish; appear mainly on buttocks, thighs, elbow creases and backs of the knees; occurs with hyperglycemia and/or hypertriglyceridemia)
  • Disseminated granuloma annulare (sharply defined ring- or arc-shaped raised areas usually on parts of the body far from the trunk)

 

How can you help your patients?

 

One of the most important ways to prevent serious skin-related complications is to help your patients living with diabetes manage their blood glucose levels since chronic hyperglycemia can lead to several skin disorders. Proper foot care (washing daily and drying thoroughly, applying moisturizer other than between the toes, inspecting daily for cuts and scrapes) is essential in minimizing the risk of foot ulcers.

 

Skin disorders are often underdiagnosed in people with diabetes, and pharmacists may be the first touchpoint for questions about skin complications. Lack of diagnosis and treatment with early-stage skin disorders can lead to clinical worsening, and progression to foot neuropathy, ulcers and even amputation, which can eventually result in fatalities. Recognition of early symptoms is vital to advise patients accordingly so they can avert serious life-threatening complications.


Helping your patients with diabetic peripheral neuropathy

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Diabetic peripheral neuropathy (DPN) is a common and very disabling disorder for those living with diabetes. Read more

The case for Continuous Glucose Monitoring (CGM)

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Many patients do not achieve their blood glucose targets using traditional self-monitoring of blood glucose (SMBG). Read more

Pharmacotherapy for managing painful diabetic neuropathy

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Diabetic neuropathies are a disabling condition and the most common form has been estimated to occur in at least 20% of people with type 1 diabetes after 20 years of disease duration, and 10-15% of newly diagnosed patients with type 2 diabetes, increasing to 50% after. Read more

Diabetic peripheral neuropathy – what you can do for your patients

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Diabetic peripheral neuropathy (DPN) is a common and very disabling disorder for those living with diabetes. Read more

Talking more than tooth decay with your patients with diabetes

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Some people call periodontal disease the sixth complication of diabetes after retinopathy, nephropathy, neuropathy, cardiovascular disease and poor wound healing. Read more

Use of non-insulin medications for type 1 diabetes

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People with type 1 diabetes are not able to produce insulin and therefore treatment has primarily focused on replacing insulin via injectable therapy. Read more

How are your patients with diabetes handling their weight?

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Since some 80-90% of people with type 2 diabetes are overweight or obese, it’s important to understand which pharmacotherapies exist for weight management. Read more

Help your patients struggling with diabetes

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When Rick Siemens from Lethbridge, graduated from the University of Alberta, he quickly realized that many of his patients with diabetes were struggling with their condition. Read more