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MAJOR THEMES;DIABETES MELLIUS, TYPES 1 and 2.DIETARY MANAGEMENT ORAL HYPOGLYCAEMICS INSULIN THERAPY.

MAJOR THEMES;DIABETES MELLIUS, TYPES 1 and 2.DIETARY MANAGEMENT ORAL HYPOGLYCAEMICS INSULIN THERAPY.
LEARNING OBJECTIVES
Following the workshop, directed and background reading, students should be able to:
1)    Outline the dietary recommendations given to patients with diabetes
2)    Discuss the place in therapy of the different oral hypoglycaemic agents
3)    Describe the different insulins available
4)    List the factors influencing choice of insulins and insulin delivery devices in diabetic patients.
DIRECTED READING
BNF Section 6.1.1-6.1.4 Drugs used in diabetes (Introduction and section headings)
National Institute for Health and Clinical Excellence. Clinical Guideline 87 Management of type 2 diabetes. May 2009.
Jacques N. New NICE guidelines for type 2 diabetes treatment. Br J Clin Pharmacy 2009;1:167-8.
Questions:
What devices/forms are insulins commonly available in?
What are the major types of insulin by onset/duration of action?
BACKGROUND READING
National Institute for Health and Clinical Excellence. Clinical Guideline 15. The diagnosis and management of type 1 diabetes in adults. July 2004. (Look at pages 5-
10)
Hackett E, Jacques N, Gallagher A. Type 1 Diabetes: Pathophysiology and diagnosis. Clinical Pharmacist 2013;5:69-72.
Hackett E, Jacques N. Type 1 Diabetes: Insulin management. Clinical Pharmacist 2013;5:69-72.
WORKSHOP EXERCISE
Example of medicine    Typical starting and maximum dose    Class    How it works to lower blood glucose    Any other notes (place in therapy, common adverse
events, contra-indications etc.)
Insulin
Metformin
500mg od-max 2g OD
.
Gliclazide
40mg OD-max 320mg in divided doses
.
Pioglitazone
15mg OD- max 45mg OD
Nateglinide
60mg TDS to max 180mg TDS
Exenatide
5mcg BD top max 10mcg BD
Sitagliptin
100mg OD
Dapagliflozin     10mg OD
ANSWER ALL THESE QUESTIONS IN DETAIL AND USE THE READING LIST ON THE PREVIOUS PAGE TO HELP ANSWER THESE QUESTIONS
Miss HH is a 65 yr old lady weighing 83kg who presents to a community pharmacy, where you regularly do a locum, asking for “something stronger for thrush which keeps
coming back”. On further questioning she is feeling increasingly lethargic recently and is complaining of going to the toilet more often. You suspect she may have
diabetes mellitus and refer her to a G.P.
She has mild osteoarthritis and is only on ibuprofen and co-codamol.
1)    What signs and symptoms of diabetes mellitus does Miss HH have? What other initial symptoms may also be present?
2)    Miss HH has heard that in one type of diabetes she will need injections. She asks you how the G.P. will determine she has diabetes and which type she has?
What are the two types and is there a precise diagnosis for diabetes?
3)    What complications can arise in someone with diabetes mellitus?
4)    What are the aims of treating diabetes?
5) The G.P. diagnoses Miss HH with type 2 diabetes and gives her dietary advice. What type of diet is recommended in diabetic patients, and why?
6)    The GP also starts Miss HH on metformin 500mg TDS. In general, is this a reasonable initial therapy? What would make it not so?
7)    A year later Miss HH is seen in clinic and it is clear her diabetes is uncontrolled. She is admitted for review of her therapy. She is on metformin 1g bd for
her diabetes and usual painkillers. Blood tests came back as:
U&Es    FBCs
Glucose    22.3 mmol/L (3.6-8)    Hb     12.1 g/dl (11.5-16.5)
HbA1c     105mmol/mol
(<48mmol/mol/6.5%)     WBC 10.2×109/l (4-11) Na            136 mmol/L (135-145)    Plts    293×109/l (150-450) K               4.8 mmol/L (3.5-5.0) Urea         11.7 mmol/L (2.5-7.5) Creatinine 250micromol/l (60-120) Wgt  80kg    Temp. 37.1 degrees Hgt   5’6’’    BP 147/85mmHg a)    Comment on Miss HH’s glucose and HbA1c in relation to NICE guidance. You can use the 2112 rule to convert old HbA1c to new units and vice versa: old to new:  -2 x 11 -2; new to old: +2 divided by 11 +2. b)    Work out Miss HH’s B.M.I. and ideal body weight. Are these relevant? BMI = wt (kg)                IBW= 50kg (men)/45.5kg (women) Ht2(m2).                 + 2.3kg for each inch > 5 feet.
c)    Comment on Miss HH’s creatinine and urea: use Cockcroft and Gault’s method to estimate her renal function.
8)    According to the BNF, and the latest NICE guidelines (2009), should we change Miss HH’s therapy? What is your suggestion?
9)    A nursing student comes to you and tells you Miss HH’s “BMs are 2.3” (Random peripheral blood glucose is 2.3 mmol/L). What are the symptoms of a hypoglycaemic
attack and how would you would treat it? Why do some patients not exhibit any symptoms?
10)    Three months later, Miss HH is taking gliclazide 160mg BD but her blood sugar remains at least 11.5mmol/L most of the day. Three possible options exist other
than starting insulin. Which of the three possibilities below might or might not be suitable for Miss HH? Which would you support? Refer to the NICE algorithm.
a) Exenatide
b) sitagliptin
c) pioglitazone
11)    After a further 6 months on pioglitazone 30mg daily and gliclazide 160mg BD, Miss HH’s HbA1c remains stubbornly high at 78mmol/mol in the diabetic clinic. The
doctor decides to stop her pioglitazone and start subcutaneous insulin therapy whilst continuing gliclazide. Describe 3 different kinds of insulin regime – suggest
preparations and doses. Which one would you recommend for Miss HH? Which regime best mimics the body’s natural insulin release?
12)    Should Miss HH be started on aspirin or a statin? (Refer to the NICE Guidance 2009).
At home, complete the care plan for Miss HH at the point of hospital admission in Q7.
Pharmaceutical care plan for Miss HH  DOB 1/6/1968 (on admission)
Problem    Desired outcome     Assessment    Actions
Options    Follow up/monitoring    Counselling
DM2
HBA1c to 6.5%
No hypos (see below)
HBA1c and glucose uncontrolled on metformin 1g BD
? Compliance
Cr= 250 micromol/L
BMs/HbA1c in longer term
Push dietary advice
How to manage hypos
Risk of hypoglycaemic attacks
Want none     None yet but risk if starts non-metformin based therapy
Cardiovascular risk
Reduce risk of CVD (CHD+stroke) plus PVD,CKD, retinopathy and nephropathy    DM2 (Uncontrolled)        BP, CBG (BM), lipids, HbA1c regularly
CKD    Stop further deterioration, avoid ESRF>> Check chronic/acute    Already lost 2/3 of GFR by age 65- bodes ill Needs tight BP (esp c ACE); tight sugar control
BP, Cr, urinary protein regularly,
VTE prophylaxis whilst in hospital
WORKSHOP TWO
MAJOR THEMES
HYPERTENSION
PRIMARY AND SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE
ISCHAEMIC HEART DISEASE
LEARNING OBJECTIVES
Following the workshop, directed and background reading, students should be able to describe/understand:
1)    Basic principles and problems in the management of hypertension
2)    The importance of considering concomitant illness in the selection of antihypertensive therapy
3)    The concept of cardiovascular risk including primary and secondary prevention of cardiovascular disease.
4)    Management of stable ischaemic heart disease
DIRECTED READING
BNF sections 2.5 Introductory pages
Stable angina. NICE Clinical Guideline CG126 2011- Quick reference guide
Management of hypertension in adults in primary care. NICE Clinical Guideline CG127 2011
MHRA and CHM. Aspirin: not licensed for primary prevention of thrombotic vascular disease. Drug Safety Update 2009;3(3):10-11.
NICE Bites – Hypertension, UKMI September 2011
NICE Bites – Management of stable angina, UKMI, September 2011
BACKGROUND READING
Stable angina – Clinical features and diagnosis. Clinical Pharmacist, January 2012
Stable angina – Management. Clinical Pharmacist, January 2012
WORKSHOP EXERCISE
Fill in the empty boxes in the diagram of the renin-angiotensin system below.
ANSWER ALL THESE QUESTIONS USE THE READING LIST IN PREVIOUS PAGE TO HELP ANSWER THESE QUESTIONS IN DETAIL
Mr KK, a 61 year old Caucasian secondary school teacher, has recently been diagnosed with hypertension. His recent blood pressure reading was 165/100mmHg.
He feels generally well but has been under a great deal of stress at work recently. He has no past medical history. His older brother has hypertension and type II
diabetes and his father died aged 52 following a myocardial infarction. He has no other medical problems. He smokes 15 cigarettes a day and weighs about 100kg.
He doesn’t think that he has hypertension as he has had only 2 high readings but he is to have 24 hour blood pressure (BP) monitoring next week. He has also had blood
tests to check his blood sugar, cholesterol, renal function and liver function. He has read about white coat hypertension in the newspaper but was not sure what this
means.
1)    Explain to Mr KK what hypertension is and what white coat hypertension is. What symptoms can you expect with hypertension? When would you start treatment?
Category    Systolic BP mmHg (Clinic)    Diastolic BP mmHg (Clinic)    Systolic BP mmHg (Ambulatory)    Diastolic BP mmHg (Ambulatory)
Normal
High-normal
Stage 1
Stage 2
2)    What lifestyle measures would you advise Mr KK to help lower his blood pressure? Why are lifestyle measures important?
3)    About 1 week later Mr KK comes back into your pharmacy, he has now had 24 hour BP monitoring and his diagnosis of hypertension has been confirmed.
a.    How should an initial antihypertensive treatment be chosen for Mr KK?
b.    What antihypertensive therapy would you choose to start Mr KK on? What target blood pressure would you recommend for Mr KK and how often would you monitor his
blood pressure?
Fill this in on your care plan.
Problem    Desired Outcome    Assessment    Actions
Options    Follow-up/ monitoring    Counselling
Hypertension
PART B: CARDIOVASCULAR RISK
4)    Mr KK has a cholesterol of 6.5mmol/L and his total cholesterol:HDL ratio is 6.5. Calculate his overall cardiovascular risk using the tables in the BNF.
Complete the table below with his modifiable and non-modifiable risk factors for CVD
Modifiable    Non-modifiable
5)    Mr KK’s doctor now wants to start other medicines for primary prevention. What do you understand by primary prevention? Suggest a drug and dosage regime if
appropriate. What counselling would you give Mr KK about any new medicines you recommend?
Fill this in on your care plan.
Problem    Desired Outcome    Assessment    Actions
Options    Follow-up/ monitoring    Counselling
Cardiovascular Risk
PART C: OTHER CO-MORBIDITIES
Although you should refer to the NICE guidance for hypertension when choosing antihypertensive therapy consideration should also be given to co-morbid conditions
6)    In four groups, discuss, giving reasons, which antihypertensive(s)
would be a good choice or poor choice. What target BP would you aim for in these patients?
•    White male accountant, 34 years old, asthma and weighs 82kg
•    White male, 70 years old, diabetes and CKD (Creatinine 250micromol/L). He weighs 70kg and is 5 feet 9 inches tall.
•    28 year old African woman with CKD (Creatinine 290micrmol/L)
•    72 year old African American woman with chronic cardiac failure NYHA Stage 3.
PART D: ISCHAEMIC HEART DISEASE
7)    About 6 months later, Mr KK visits your pharmacy again. He tells you
his GP has diagnosed him as having angina. What is angina and what symptoms would you expect him to experience?
8)    What changes would you recommend to Mr KK’s prescription and why? What counselling and monitoring would he need?
9)    Mr KK comes back to your pharmacy 3 months later with a prescription for a GTN spray. You notice this will be his 4th repeat prescription for this in the last
3 months. What questions do you want to ask him before you dispense this and what changes could you suggest to his therapy?
Question        Response
10)    Mr KK collects a new prescription for his GTN spray and asks you when he should expect to need a new one. Each GTN spray contains 200sprays; Mr KK is now using
2 puffs 4 times a week. The spray you have dispensed for him expires in May 2015.
WORKSHOP THREE
MAJOR THEMES:
CHRONIC HEART FAILURE
LEARNING OBJECTIVES
Following the lecture, workshop, directed and background reading, students should be able to:
1)     Describe the aetiology and presentation of heart failure
2)     List the desired outcomes in care of patients with heart failure and how
pharmacists can help achieve these
3)     Discuss the pharmaceutical management of heart failure
4)     Outline how to initiate and titrate angiotensin converting enzyme inhibitor (ACEI) therapy and beta blocker therapy
5)    List the counselling required by patients commencing therapy on ACEIs and beta blockers for heart failure
DIRECTED READING
Karagkounis D. Heart Failure – clinical features and diagnosis. Clinical Pharmacist. 2014; 6: 119-122 2010
Williams H. Heart Failure – management. Clinical Pharmacist. 2014; 6:123-1282010
BNF sections 2.5.5
NICE Bites – Chronic Heart Failure (NW MI) September 2010
NICE Clinical Guideline No: 108 August 2010: Management of Chronic Heart Failure in adults in Primary and Secondary Care. NICE guideline Pages 15-20 Pharmacological
Treatment of Heart Failure and Appendix D – Practical Notes
BACKGROUND READING
Myocardial infarction; secondary prevention – NICE Guidelines 2007 – quick reference guide. May 2007
Chapter on Congestive Cardiac Failure) in Clinical Pharmacy and Therapeutics or similar textbook
PRE- WORKSHOP LEARNING – A HEART FAILURE FORMULARY
For each of the following group of drugs for heart failure indicate initiation and maximum dose and what stage of heart failure they should be used.
Beta-blockers (Licensed in heart failure)
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose
Angiotensin Converting Enzyme Inhibitors
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose
Angiotensin II Receptor Antagonist (Licensed in heart failure)
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose
Aldosterone Antagonists
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose
Loop diuretics
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose
Thiazide diuretics
When are they indicated:…………………………………………………..
Name    Initiation dose    Maximum dose
WORKSHOP THREE: ANSWER ALL THESE QUESTIONS USING THE READING LIST IN THE PREVIOUS PAGE TO HELP YOU ANSWER THESE QUESTIONS PLEASE ANSWER THEM IN DETAIL
Mrs LL a 70 year old lady attended her GP practice as she had noticed that she had become increasingly tired and short of breath on carrying out her usual activities.
PC     Increased tiredness, SOB and swollen ankles
HPC   She noticed she needed to stop for breath when walking up the stairs.
Feeling tired and lethargic as not sleeping well at night for the last 2/52. Legs are feeling heavy and her shoes feel tight.
PMH    IHD, OA, MI 4 yrs ago
SHx    Lives alone in a house, usually independent, doesn’t drink any alcohol, ex-smoker, quit after her MI
RS    Basal creps in both lower bases, cough for past week producing watery sputum
CVS    BP 150/95mmHg    Pulse 90bpm reg
CNS     Grossly intact
O/E    Pitting oedema on both feet
Weight today = 67kg
Last recorded weight (4 months ago) in practice records = 60kg
Working diagnosis:    Heart failure/COPD/General deterioration
Current Rx:    Simvastatin 40mg nocte
Aspirin dispersible 75mg mane
Atenolol 50mg Mane
Ramipril 1.25mg Mane
GTN spray 400mcg 1-2 sprays when required for chest pain
1.    What do you understand by the term heart failure?
2. What medical conditions can lead to the development of heart failure?
3. What signs and symptoms does Mrs LL have that may be suggestive of
heart failure? How do these arise?
4. How would the diagnosis of heart failure in Mrs LL be confirmed?
5. What treatment option would you add to Mrs LL whilst she is awaiting her ECHO and specialist review? Include a suggested dose, preferred route of administration,
any monitoring required, and counselling you should offer Mrs LL.
Mrs LL is seen by a Cardiologist and her ECHO confirms that she has Left Ventricular Systolic Dysfunction (LVSD) with an Ejection Fraction of 30%. The aetiology of her
heart failure is due to ischaemia. The Cardiologist felt no further interventions or stents would be beneficial and optimisation of medical management was the plan.
Mrs LL was referred to the local Community heart failure nurses for optimisation.
On her first appointment the recommendation is to titrate ramipril to 2.5mg daily and switch atenolol to bisoprolol 2.5mg once daily.
6.   Why are angiotensin converting enzyme (ACE) inhibitors and beta-blockers recommended first line in the management of heart failure?
7.    a) How should ACE therapy be titrated and what monitoring is required?
b) What are the main side effects of ACE inhibitors? How should they be managed?
8.    a) How should beta-blockers be initiated in heart failure and what monitoring is required?
b) Why was Mrs LL switched from atenolol to bisoprolol?
c) In which situations are beta –blockers contra-indicated?
d) What are the main side effects of beta –blockers and how can they be managed?
9.    Mrs LL wants to know how many pints of water she can drink in a day? Calculate and advise Mrs LL. (1 pint = 568ml)
Mrs LL attends for a follow up appointment at the heart failure clinic she has noticed an increase in breathlessness since her last appointment and simple things like
brushing her teeth and getting dressed can make her extremely tired. Her osteoarthritis pain has worsened and her GP has given her a new prescription for her pain.
Current Treatment:
Simvastatin 40mg nocte
Aspirin dispersible 75mg mane
Bisoprolol 10mg Mane
Ramipril 10 mg Mane
Furosemide 40mg Mane
GTN spray 400mcg PRN
Naproxen 500mg TDS
Bloods: Creatinine 120micromol/L (60-120), urea 9mmol/L (2.5-7.5), potassium 4.5mmol/L (3.5-5)
BP 130/80mmHg, HR 65bpm. mild ankle swelling and lungs clear.
10.    Using the New York Heart Association (NYHA) functional classification,
how would you grade the severity of Mrs LL’s heart failure? Give reasons for your answer.
11.    Could any of Mrs LL’s drug treatments exacerbate her heart failure? If so,
how? Can you suggest alternative treatments that would not exacerbate her heart failure? Fill this in on your care plan.
12. Which other classes of drugs can precipitate or exacerbate heart failure?
13.    If Mrs LL’s heart failure were not controlled on her first-line agents, what second-line agents are available to add in?
14.    Two weeks later Mrs LL’s potassium is reported as 6.6 mmol/L. What is
likely to have caused this and what would you recommend?
Pharmaceutical care plan for Mrs LL (on review clinic at question 11)
Problem    Desired Outcome     Assessment    Actions
Options    Follow up / monitoring    Counselling
Worsening Heart Failure symptoms following titration of ACEi and BB.
Osteoarthritis
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