This fact sheet is dedicated to the role of the pharmacist in the fight against what is now considered the 'pandemic' of the new millennium: the Diabetes Mellitus.
The pharmacist is called upon, first and foremost, to act as an interface with the diabetic patient in the dispensing of medicines and other medical devices which the patient has to purchase and, in this context, can promote through its counselling activities full adherence to prescriptions and lifestyles aimed at proper glycaemic control.
Pharmacies also represent, given the capillarity of their territorial distribution, a practically irreplaceable outpost in the screening campaignsoften organised on World Diabetes Day and aimed at promoting both self-diagnosis and full therapeutic compliance.
We therefore offer a first fact sheet with an overall overview of diabetic disease, which will be followed by a second fact sheet in which the serious ocular complications of the disease will be dealt with in depth.
Diabetes: a growing disease
The diabetes mellitus (DM) encompasses a group of metabolic disorders resulting from a decrease in insulin activity, caused by a reduced availability of this hormone, an impediment to its normal action or a combination of the two.
A distinctive feature of diabetes mellitus is thehyperglycaemiathe presence of high blood glucose levels, with which certain complications are associated over time:
– macrovascular alterationsconsisting in the development of particularly severe and early atherosclerosis,
– microvascular alterations, i.e. microcirculation alterations specific to diabetic disease, which are particularly manifest in the retina, kidney and nervous system.
Diabetes is on the rise throughout the worldespecially among people of working age, with decidedly alarming numbers: according to IDF (International Diabetes Federation) data, in 2015, 415 million adults (1 in 11) worldwide had diabetes, with a prevalence rate of 8.3 %, by 2040, 642 million people are expected to be ill, with a prevalence rate of 10.4%.
As for theItaly 2017 data from the ARNO Diabetes Observatory, a collaboration between SID (Italian Society of Diabetology) and CINECA, document that the total prevalence rate of diabetes in Italy is 6.34%.
There are no official registers for this pathology and the number of people with diabetes is estimated on the basis of sources such as prescriptions for at least one hypoglycaemic drug, diabetes exemptions and primary or secondary diagnosis of diabetes mellitus, to which should be added the quota consisting of patients on diet therapy only, with no exemption from co-pay and never admitted to hospital. Then there are the cases of misdiabetes, which, according to recent estimates, correspond to approximately 20% of the total. Considering all these components, the overall prevalence of diabetes in Italy could be around 8%, with about 4 million known cases and 1 million misrecognised cases.
In addition, around 10 million people have a form of so-called 'pre-diabetes' (a condition characterised by impaired fasting blood glucose and/or impaired glucose tolerance), or previous gestational diabetes, or first-degree family history of diabetes, obesity or central overweight. If these people do nothing to prevent their development, it is estimated that at least 2 million of them will develop diabetes within the next 10 years.
On the cost side, the International Diabetes Federation's (IDF) Diabetes Atlas published estimates of diabetes-related healthcare expenditure worldwide and the cost growth was impressive, rising from USD 232 billion in 2007 to USD 727 million in 2017 for the care of diabetics aged 20-79 years.
Type 1 and type 2 diabetes
There are two main forms of diabetes mellitus: type 1 diabetes and type 2 diabetes. Both types of diabetes are preceded by a phase of impaired glucose homeostasis, which becomes more pronounced as the disease process progresses.
- The type 1 diabetes is the consequence of total or near-total insulin deficiency. In the majority of cases it is the immune-mediated form. In approximately 90% of type 1 diabetics, at the onset of the disease, the presence in the plasma of autoantibodies directed against pancreatic beta cells (which produce insulin) can be shown to be the cause of their destruction. In this form of diabetes, in which there is an almost absolute deficiency of insulin, this hormone must be administered as replacement therapy. For this reason, type 1 diabetes was formerly referred to as insulin-dependent diabetes (IDDM) or childhood-onset diabetes, given its onset generally before the age of 30.
-The type 2 diabetes is a heterogeneous group of alterations characterised by varying degrees of insulin resistance, impaired insulin secretion and increased glucose production. It represents the most common form of diabetes, and is preceded by an early phase of altered glucose homeostasis, defined as "glucose intolerance'. At this stage, hyperglycaemia can be controlled by a combination of behavioural measures, such as diet and exercise, and medical treatment, with drugs that increase peripheral insulin sensitivity or reduce hepatic glucose production. In the past, this form of diabetes was called non-insulin-dependent diabetes (NIDDM) or diabetes of adulthood or maturity; this term has now become obsolete as many individuals with type 2 diabetes eventually require insulin treatment to control blood glucose. Moreover, although this form develops more typically with advancing years, it is nowadays diagnosed more frequently in children and young adults, particularly obese adolescents with a sedentary lifestyle.
In fact, the prevalence of type 2 diabetes appears to be growing in parallel with the increase in the global obesity rate. The World Health Organisation (WHO) has recognised a condition referred to as the 'global obesity epidemic' and a parallel 'global diabetes epidemic', which are rapidly emerging especially in developing countries.
The role of the pharmacist
The pharmacist can play a very important role in providing, at the patient's request, correct information on the drugs he dispenses, since it is right that the person with diabetes (or his family member) should know, in broad terms, how the active ingredient he is taking works, what therapeutic benefits it can bring, and, above all, the possible side effects, both those that are of no importance to the doctor but unpleasant for the patient, and those that the patient might underestimate, but which should be reported to the doctor because they could be significant.
The main classes of oral anti-diabetics (also improperly called oral hypoglycaemic drugs) used to treat type 2 diabetes are:
- biguanides
- sulfonylureas
- glinides
- glitazones (or thiazolidinediones)
- DPP-4 enzyme inhibitors
- intestinal alpha-glucosidase inhibitors
- inhibitors of the renal glucose transporter SGLT-2
Biguanides and glitazones increase insulin sensitivity. Sulfonylureas and glinides increase insulin secretion. DPP-4 enzyme inhibitors slow down the breakdown of a hormone (GLP-1) that is produced by the intestine and stimulates insulin secretion and inhibits glucagon secretion from the pancreas. Intestinal alpha-glucosidase inhibitors delay the absorption of dietary glucose. Inhibitors of the renal glucose transporter SGLT-2 increase, the renal elimination of glucose.
The patient must follow the specific prescription and, in general, oral anti-diabetics should be taken before meals, 1 to 3 times a day, depending on the duration of action and the patient's needs. In many cases, correction of hyperglycaemia requires the use of 2-4 oral drugs, exploiting complementary mechanisms of action. In other cases, oral drugs may be combined with insulin, most often of the intermediate or long-acting type, taken once daily.
Many diabetic patients, however, fail to reach their target glycaemic levels, resulting in an increased risk of co-morbidities, i.e. of developing complications such as cardiovascular diseases, stroke, nephropathy, neuropathies, and as far as the ocular district is concerned, retinopathy and diabetic macular oedema
In this sense, the pharmacist's function to promote full patient adherence to prescribed therapeutic regimes is important.
The problem of prevention
A separate discussion deserves the prevention strategy, both primary and secondary.
- The primary prevention consists of stimulating the patient to adopt a healthy lifestyle with an adequate diet and moderate physical activity to control overweight by counteracting sedentary lifestyles.
Clinical studies show that a healthy lifestyle can reduce the incidence of diabetes by up to 70%.
We must, in fact, become fully aware that the prevention of obesity and diabetes begins in daily life, such as at the table, promoting not the culture of deprivation, but rather the culture of a healthy and correct dietary-nutritional therapy, entrusted to specialists.
- The secondary prevention consists of providing the diabetic patient with all the tools to prevent complications, from cardiovascular to ocular. Effective treatment involves monitoring blood glucose, blood pressure and blood lipid levels.
The data reported by the Steno-2 study show that, after 13 years, in high-risk patients with type 2 diabetes, acting on all these factors simultaneously and adopting a treatment programme with multiple drug combinations and lifestyle changes achieved a reduction of up to 50% in the risk of death and the most serious complications of diabetes.
Self-management education
Approximately 50% of people with diabetes have unsatisfactory blood glucose and blood pressure control. The many causes include the psychological difficulty in accepting the condition and all that goes with it, lack of support in the family, lack of knowledge about the disease and its complications, lack of understanding of the protocol for managing medicines and controls, mistrust in the doctor or health care, long waiting times, and finally financial problems.
Promoting self-management, therefore, means aiming to achieve an articulated set of objectives, such as:
- raise awareness of the risk factors onset of diabetes, strategies for preventing the disease and its complications
- improve the knowledge on diabetes, its control and self-monitoring.
- raise awareness among health providers in general and promote a more comprehensive and integrated approach to the disease
- promote public health initiatives to improve the quality of life of diabetes patients, from the screening to the creation of dedicated waiting lists for regular check-ups, which can be booked directly with the diabetologist and/or family doctor.
This article can also be downloaded in PDF format
Sheet No 10 - Pharmacist and the diabetic patient
© Copyright 'l'Oculista italiano' - January 2020
Dr. Carmelo Chines
Direttore responsabile
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