diabetes tech program_final

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D I A B E T ES :

OVERVIEW, DIAGNOSIS, AND PHARMACOLOGIC MANAGEMENT FOR PHARMACY

TECHNICIANS

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Diabetes: Overview, Diagnosis, and Pharmacologic

Management for Pharmacy Technicians

AccreditationPharmacy Technicians: 0798-0000-15-048-L01-T

FacultyKevin McCarthy, RPhVice-President, PharmCon

Krystin FieldsHealth Promotion Intern PharmCon

CE Credit(s)1 .00 contact hour(s)

Faculty DisclosureProfessor Kreckel and Dr. Garofoli have no actual or potential conflicts of interest in relation to this program.

Learning Objectives• Describe the origin of insulin and insulin’s function in the body• Differentiate between Type 1, Type 2, and Gestational Diabetes• Describe various classes of medication used in the treatment of diabetes• List two ways pharmacy technicians can assist pharmacists in the care of diabetic patients. Legal DisclaimerThe material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity.


Objectives • Describe the origin of insulin and insulin’s

function in the body• Differentiate between Type 1, Type 2, and

Gestational Diabetes• Describe various classes of medication

used in the treatment of diabetes• List two ways pharmacy technicians can

assist pharmacists in the care of diabetic patients.


The History of Diabetes•Diabetes mellitus has been a medical condition for at least 3500 years (Brar, 2010).

• In the early 1920s, researchers strongly suspected that diabetes was caused by a malfunction in the digestive system related to the pancreas gland (a small organ that sits on top of the liver) (Brar, 2010).


Today’s Diabetes• About 20 million people in the United States have

diabetes mellitus.

• Diabetes is a serious, lifelong disorder that is incurable as of today.

• Although diabetes occurs most often in adults, it is the second most common chronic disorder after cancer in U.S. children. There are about 200,000 children and teenagers diagnosed with diabetes.

• The modern American lifestyle is a factor in the rise of diabetes as it includes less activity and unhealthy diets compared with the past.

(Shane-McWhorter, 2005)


Brief Diabetes Overview• Diabetes is a disorder of metabolism—the way the

body uses digested food for growth and energy.



• A vital organ that makes enzymes used in digestion and also hormones, such as insulin, which regulates blood sugar levels.

(O’Connor, 2013)

Pancreas


The Anatomy of the Pancreas

• The pancreas is about 15 to 18 centimeters long, weighs 100 grams and is located in the abdominal cavity.

• The head of the pancreas is situated in the loop of the small intestine that forms at the site where the small intestine joins the stomach.

(O’Connor, 2013)


Normal Pancreatic Function• Insulin secretion from the pancreas is

stimulated or inhibited by several factors:

• Blood glucose level is the most important factor in the release of insulin from the beta cells that produce glucagon and insulin. If blood glucose increases, insulin is released until glucose levels return to normal.

• When insulin is released into the bloodstream, it stimulates the uptake of glucose (removal from the blood).

• Glucagon is an antagonist of insulin. It is released in response to low levels of glucose and acts on cells to release glucose, amino acids, and fatty acids into the circulatory system.

(O’Connor, 2013).


Diabetes and the Pancreas• Diseases of the pancreas can be divided into two

basic categories:

• Exocrine disorders (related to problems involving the digestive enzymes that the pancreas secretes)

• Endocrine disorders (related to problems involving the hormones that the pancreas secretes, such as insulin)

• The most common endocrine disease of the pancreas is diabetes mellitus.

• Diabetes mellitus may be further classified as insulin-dependent (commonly called juvenile diabetes or type 1), non-insulin-dependent or adult-onset diabetes (type 2), gestational diabetes (occurs during pregnancy), or secondary diabetes (diabetes that results as a consequence of another condition).

(O’Connor, 2013)


Poll Question• Where in the body is insulin created: • Kidney• Pancreas• Thyroid• Small intestine


What is Diabetes?• When people without diabetes eat, the

pancreas automatically produces the right amount of insulin to use or store blood glucose.

• In people with diabetes, not enough insulin

• Build up of glucose

(Rees, 1997)


Diagnosis of Diabetes• Presence of early symptoms such as excessive thirst

and frequent urination.

• Blood glucose test

• Oral glucose tolerance test


Gestational Diabetes• Gestational diabetes develops during

pregnancy. • The condition usually resolves when the

pregnancy is over• Gestational diabetes develops most frequently

in the middle and later months of pregnancy• Pregnant women are given the oral glucose

tolerance test during their well visits to their OBGYN to screen for gestational diabetes.

(Rees, 1997)


Gestational Diabetes • Blood glucose monitoring and treatment with insulin

can ensure that a baby born to a mother with diabetes will be healthy.

• Treatment consists of a healthy diet, physician approved exercise, and insulin.

• Oral medications are not used in patients with gestational diabetes because of the effects these medications would have on the baby.

• Approximately half of women with gestational diabetes will no longer have abnormal blood glucose tests shortly after giving birth.

• Many women with gestational diabetes will develop noninsulin dependent diabetes later in their lives.

(Rees, 1997).


Type 1 Diabetes• Individuals with type 1 diabetes are insulin-

dependent.

• This means that the pancreas either does not produce insulin at all or it produces too little to get rid of excess glucose in the blood on its own.

• The disease starts at an early age and is sometimes referred to as juvenile diabetes.

• A person with Type 1 diabetes will most likely appear thin in stature

• (O’Connor, 2013)


Symptoms of Type 1 Diabetes

•Frequent urination, extreme thirst, constant hunger, blurred vision, and extreme fatigue.

•The symptoms of type 1 diabetes can be sudden and severe.

(Rees, 1997)


Pathology of Type 1 Diabetes

• No one knows exactly what causes type 1 diabetes.

• What is clear is that the body's own immune system turns against the body's own tissues. Certain substances formed by the immune system attack the beta cells of the pancreas, destroying their ability to make insulin.

• Some researches have proposed that a trigger may be involved with the onset of the disease such as viral infections, however, none of these theories have been proven to be true.

(Rees, 1997)


Type 1 Diabetes Treatment• A person with type 1 diabetes must have

insulin injections to survive. • Oral medications are not used to treat

Type 1 Diabetes• Without insulin, symptoms worsen until

the patient loses consciousness and slips into a coma. • Treatment for type 1 includes a daily

routine of insulin shots or use of an insulin pump to replace what their own pancreas is not making.

(Rees, 1997)


Type 1 Diabetes Non Drug Treatments

• Reducing fats and cholesterol can help reduce the risk of heart disease, which affects people with diabetes more often than those with normal glucose metabolism.

• Exercise and eating a healthy diet can help reduce the risk of heart disease. Being fit can also bring a sense of wellbeing and strength that has special meaning for someone with a chronic illness like diabetes. (Rees, 1997)


Type 2 Diabetes• Type 2 diabetics either do not produce

enough insulin on their own, or the cells in the body do not use the insulin properly

• These patients are often resistant to the effects of insulin. This resistance can increase the longer the patient has diabetes and the more uncontrolled the disease.

• Type 2 diabetics often appear overweight or obese in stature, although this is not always the case

(O’Connor, 2013)


Type 2 Diabetes (cont)• Although the causes are unknown, we do know that insulin

resistance plays a huge role in type 2 diabetes. • Possible causes of insulin resistance:• The first could be a defect in insulin receptors on cells. Like an

appliance that needs to be plugged into an electrical outlet, insulin has to bind to a receptor to function. Several things can go wrong with receptors. There may not be enough receptors for insulin to bind to, or a defect in the receptors may prevent insulin from binding.

• A second possible cause involves the process that occurs after insulin plugs into the receptor. Insulin may bind to the receptor, but the cells don't read the signal to metabolize the glucose. It would be like sending a text message to a friend, but when they receive it it’s in a language that they cannot understand (the signal that the insulin sends cannot be read properly).


Symptoms of Type 2 Diabetes

• The symptoms are less severe than those associated with type 1. • The symptoms of diabetes may begin

gradually and can be hard to identify at first. They may include fatigue, a sick feeling, frequent urination, especially at night, and excessive thirst. • Other symptoms may include sudden weight

loss, blurred vision, and slow healing of skin, gum and urinary tract infections. Women may notice genital itching.

(Rees, 1997)


Risk Factors for Developing Type 2

Diabetes


Treatment Rationale and Approaches

• One way to reduce the risk of diabetic related complications is to keep blood sugar levels under control (within the normal range of someone who does not have diabetes)

• A healthy diet that helps the person maintain normal weight is also very important.

• In some people, exercise can help keep weight and diabetes under control.

• When diet and exercise alone can't control diabetes, medications are available.

(Rees, 1997)


Diabetes and a Healthy Diet• The proper diet is critical to diabetes

treatment. It can help someone with diabetes:

1. Achieve and maintain desirable weight. 2. Maintain normal blood glucose levels.3. Prevent heart and blood vessel diseases

(conditions that tend to occur in people with diabetes.)

(Rees, 1997)


Alcohol Intake for DiabeticsMost people with diabetes can drink alcohol safely if they drink in moderation (one or two drinks occasionally.) In higher quantities alcohol can cause health problems.

• Alcohol has calories without the vitamins, minerals, and other nutrients that are essential for maintaining good health.

• Alcohol on an empty stomach can cause low blood glucose or hypoglycemia. Hypoglycemia is a particular risk in people who use oral medications or insulin for diabetes.

• Oral diabetes medications, especially from the class called sulfonyureas, can cause dizziness, flushing, and nausea when combined with alcohol. (Rees, 1997)


Exercise and the Diabetic• Exercise has many benefits, and for someone with

diabetes, regular exercise combined with a good diet can help control diabetes.

• Exercise not only burns calories, which can help with weight reduction, it also can improve the body's response to the hormone insulin.

• Exercise also reduces some risk factors for heart disease. For example, exercise can lower fat and cholesterol levels in blood, which increase heart disease risk.

(Rees, 1997)

Before:

• Include 5 minute warm up

• Check Blood Sugar

After:

• Include 5 minute cool down

• Check Blood Sugar


Classes of Medications• There are many diverse classes of medications that

function in different ways to lower blood sugar levels. These classes include:

• Insulin• Biguanides • Sulfonylureas• Meglitinides• Thiazolidinediones• Alpha-glucosidase inhibitors• Sodium-glucose transporter 2 inhibitors (SGLT2 inhibitors)• DPP-4 inhibitors• GLP-1 agonists

Oral Medicatio

ns

(What are my options?, 2014)


Insulin• Insulin is used to treat type 1 diabetes and

gestational diabetes. • Not all injectable diabetes medications are

insulin. • Afrezza® is a new form of insulin is inhaled

instead of injected like most insulins• Insulin is also a treatment option for some

patients with type 2 diabetes.


Insulin (cont)A person also may have to take insulin if his or her blood glucose fluctuates a great deal and is difficult to control.

Common Brand Names of Injectable and Inhaled InsulinsHumalog kwikpen, Novolog Humulin, NovolinHumulin 70/30, Novolin 70/30 Humulin R, Novolin RHumulin N, Novolin N Humalog mix 75/25, Novolog

mix 70/30Humalog Mix 50/50 LantusApidra ToujeoLevemir Afrezza


Biguanides• Decreases the body’s need for insulin.

• Metformin (Glucophage®, Glucophage XR®) is the mainstay of treatment for patients with type 2 diabetes and for some metformin is sufficient to control their blood sugar

• Metformin it may be used in combination with other medications and is one of the ingredients in many of the commercially available combination products


Sulfonylureas and Meglitinides

Sulfonylureas stimulate cells of the pancreas to release more insulin. Common sulfonylureas seen in the pharmacy include:

• glimepiride (Amaryl®)• glipizide (Glucotrol®, Glucotrol XL®)• glyburide (Diabeta®, Glynase, Micronase®)• chlorpropamide (Diabinase®)

Meglitinides are similar to sulfonylureas in that they also stimulate cells in the pancreas to release insulin.Although not used as commonly, you may see these in combination with other medications:

• nateglinide (Starlix®)• repaglinide (Prandin®)


Thiazolidinediones and Alpha-Glucosidase

Inhibitors• Thiazolidinediones help improve insulin resistance and also

reduce the amount of glucose produced by the liver.• The two thiazolidinediones approved in the U.S. are

Pioglitazone (Actos®) and rosiglitazone (Avandia®). • Alpha-Glucosidase Inhibitors must be taken with the first bite

of food because they work by slowing the digestion of complex carbohydrates (slows the release of sugars into the blood stream to give the body more time to break down the sugars without having a quick increase in blood sugar)

• Not used as often in practice because we have medications that work better

• Recognize the names:• Acarbose (Precose®)• Miglitol (Glyset®)


Sodium-glucose transporter 2 inhibitors (SGLT2 inhibitors)

• These are the “gliflozin” drugs• Sodium-glucose transporter 2 works in the

kidney to reabsorb glucose and the medication, SGLT2 inhibitors, block the reabsorption of glucose by sodium-glucose transporter 2 in the kidney and cause extra glucose to be released in the urine.• Recognize the drugs in the pharmacy:

• Canagliflozin (Invokana®)• Dapagliflozin (Farxiga®)• Empagliflozin (Jardiance®)


Dipeptidyl Peptidase- IV Inhibitors

(DPP-4 inhibitors)• One of the newer classes that also have a unique target of action

to fight diabetes

• Can be recognized because they end in “gliptin”

• DPP-4 inhibitors work by preventing the breakdown of a naturally occurring compound in the body called GLP-1 that reduces blood glucose levels in the body.

• Recognize them in the pharmacy:

• Sitagliptin (Januvia®)• Saxagliptin (Onglyza®)• Linagliptin (Tradjenta®)• Alogliptin (Nesina®)


Glucagon-like Peptide-1 Receptor Agonists (GLP-1 Agonists)

• Injectable products that differ mostly in their dosing schedule (daily, once a week)

• Exerts its main effect by enhancing the natural effects of a substance (GLP-1) that helps to increase insulin secretion from the pancreas in response to food

• Also slows gastric emptying (which may help give more time for our natural processes to properly break down and get rid of sugars)

• Recognized the medications in this class:• Liraglutide (Victoza®)• Exenatide (Byetta®)• Exenatide LAR (Bydureon®)• Albiglutide (Tanzeum®)• Dulaglutide (Trulicity®)


Poll Question• Which of the following symptoms are not

associated with type 1 diabetes?• Excessive thirst • Increased hair loss• Increased appetite• Increased urination


Medications Working Together

• All of the drugs discussed previously work in different ways to lower blood glucose levels and because of that, may be used together for successfully managing diabetes when taking only one medication proves to be ineffective in improving blood glucose levels.• We balance trying to achieve normal

blood sugar levels with avoiding adverse side effects of diabetes medications, especially when used in combination


The Importance of Treatment• A key goal of diabetes treatment is to

prevent complications because, over time, diabetes can damage the heart, blood vessels, eyes, kidneys, and nerves.

• It's important to diagnose and treat diabetes early, because it can cause damage even before it makes someone feel ill.


Diabetes and Pharmacy Technicians

Medication reconciliation- should occur every time a patient brings a new prescription for a new medication.

• This is how we know that the patient understands what medications have been stopped and which one is supposed to replace the old one or whether the new medicine is to be taken in addition to other diabetes medications.

• This saves the pharmacist time and wasted energy trying to contact the patient or physician when it’s time to check the medication

Keep up to date on new medications when they come out and know which class they belong to

• This helps avoid accidental duplications in medications• This saves time and makes filling prescriptions easier

when patients ask for their diabetes medicine (example: if they ask for their insulin you know to fill the Levemir, not the Byetta (because even though both are injectable only 1 is an insulin)



Diabetes and Pharmacy Technicians

• One of the most important ways that a technician can impact the care of a diabetic patient in a positive way is to encourage adherence to medication every time the opportunity presents itself

• It’s all about being the one that opens up communication lines (whether in person or over the phone) with the pharmacist.

• Politely question non-adherence and try to get to the bottom of the problem.•If cost of the medication is a problem, offer to try to find an online

coupon available from many of the manufacturers or offer to let the patient speak to the pharmacist for advice on less costly alternatives if coupons are not appropriate for the patient (Medicare or Medicaid typically cannot use coupons).

•If side effects are a problem, alert the pharmacist so that they can counsel the patient on ways to alleviate side effects.

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