Introduction: blood sugar level) with disruption of carbohydrate, fat,

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 (