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How should you discuss gliclazide in an MUR?

gliclazide tablets

What do you need to know before advising patients on this commonly dispensed diabetes medicine?

Gliclazide is an oral antidiabetic medication used for the treatment of non-insulin-dependent diabetes mellitus (type 2 diabetes).

Patients with diabetes are considered relevant for a medicines use review (MUR) if they fall into the national target group of patients who are at risk of, or have been diagnosed with, cardiovascular disease and are regularly being prescribed at least four medicines.

mur gliclazide

What is gliclazide used for?

Gliclazide is a second generation sulphonylurea, which acts by stimulating insulin secretion from the beta cells in the islets of Langerhans in the pancreas. It is important for pharmacy staff to understand its mechanism of action, as patients may ask you to explain how their gliclazide medication works. Improving their understanding may improve adherence.

When diabetes cannot be controlled by diet alone, gliclazide is commonly prescribed as first-line treatment in patients for whom metformin is not appropriate, or in combination with metformin for patients who have not achieved appropriate glycaemic control with this medicine alone.

Gliclazide can also be used in combination with other medicines, when monotherapy is inadequate at controlling type 2 diabetes. For further guidance on the range of medications used in this condition, read the C+D Update article Drugs used to manage type 2 diabetes.

What could you discuss during an MUR?

Initially, you should establish if the patient is taking the correct dose, and whether they are adhering to their prescribed treatment regimen.

Simple questions may uncover non-adherence: “When was the last time you missed your gliclazide dose?”; “Do you ever avoid taking your medication?”; “When was the last time you had problems taking your medicine?”

For the treatment of type 2 diabetes in adults, the initial dose range is 40-80mg once daily with breakfast using immediate-release medicines. The dose should be adjusted according to individual patient response and may be increased if necessary, up to a maximum of 320mg daily (given in divided doses). For those with more frequent dosing of immediate-release gliclazide, tablets should always be taken with meals.

For modified-release gliclazide, the initial dose is 30mg daily, with the dose adjusted according to response every four weeks, up to a maximum of 120mg daily. Gliclazide modified-release 30mg is considered to be approximately equivalent in therapeutic effect to immediate-release gliclazide 80mg. For full dosing details, consult the British National Formulary (BNF).

Side effects of gliclazide

As with any medication, there are a wide range of side effects that you should be aware of and watch out for during an MUR. Patients may not realise that their medication is causing a particular symptom, so it is important you ask patients if they have had any other recent health problems, even if they think it is not related to their condition.

Many of the side effects which can occur do so in the first six to eight weeks of treatment. These may include:

  • allergic skin reactions
  • gastrointestinal disturbances, including nausea, vomiting and indigestion
  • diarrhoea
  • constipation
  • jaundice
  • hypersensitivity reactions.

Sulphonylureas are also associated with weight gain, and patients may find they put on weight while being treated with gliclazide. Counselling patients on alcohol intake, suitable exercise and eating a healthy balanced diet can help to prevent excess weight gain.

gliclazide weight gain

If a patient is experiencing gastrointestinal side effects, you should ensure they are taking their gliclazide with a meal and to avoid rich or spicy foods. Small sips of water can help during diarrhoea and vomiting, and you may recommend oral rehydration sachets to prevent dehydration. High-fibre foods and water, as well as increasing exercise, can be recommended to prevent constipation.

Although rare, gliclazide can cause hypoglycaemia (low blood sugar), which is why patients are prescribed it in the morning with breakfast. You should ensure patients are aware of the symptoms of this conditions, as it may require immediate medical attention.

Early warning signs of hypoglycaemia can include:

  • feeling hungry
  • trembling or shaking
  • sweating
  • confusion
  • difficulty concentrating.

Hypoglycaemia is more likely to occur if a patient is taking gliclazide and:

  • takes too much
  • skips a meal
  • increases their exercises without eating more to compensate
  • takes concomitant medication that lowers blood glucose levels
  • has a concurrent illness eg viral infection
  • drinks alcohol.

It is important to remind patients that hypoglycaemia can be prevented by having regular meals. Patients should be advised to carry a fast-acting carbohydrate such as fruit juice, glucose tablets or sugar cubes in case their blood sugar gets too low – but if this doesn’t help or if symptoms return, they should seek immediate medical attention.

Use of sulfonylureas in pregnancy and breastfeeding

The use of sulfonylureas in pregnancy and breastfeeding should be avoided due to the risk of neonatal hypoglycaemia. If a diabetic patient becomes pregnant while taking gliclazide, they should be referred to their GP who may reconsider their current treatment.

Prescribing considerations

Gliclazide is primarily metabolised by the liver, before being excreted primarily through the kidneys. Bearing this in mind, you should be aware that there is an increased risk of hypoglycaemia in hepatic impairment. You should advise prescribers that gliclazide should be avoided or used at a reduced dose in patients with severe hepatic impairment.

In patients with renal impairment, the lowest possible dose to achieve glycaemic control should be used. Blood glucose levels should be carefully monitored in these patients.

What else should you be aware of?

During an MUR, you should ask if the patient regularly attends their diabetic check-ups, and when they last had their HbA1C levels monitored – this should be every three to six months.

It is important to ensure patients who drive are aware of the potential dangers of hypoglycaemia and the implications this may have. Patients should be reminded of the symptoms of hypoglycaemia and advised not to drive if they are feeling unwell. They may also need to inform the Driver and Vehicle Licensing Agency (DVLA) if they experience an episode of severe hypoglycaemia while driving. Guidelines can be found here.

Further reading

MUR Zone

9 Comments

Ilove Pharmacy, Non Pharmacist Branch Manager

1. Get patient to sign consent form

2. £28.

Mohammed Patel, Community pharmacist

It is nothing other than insane to ask pharmacists to perform these useless actions.

The patients DO NOT WANT THEM. The pharmacists DO NOT HAVE TIME TO DO THEM. And the GP's simply don't care and assume the results were wrong so that they can do their own tests/interviews in the surgery (more $$$ from NHS to the doctors).

In either case, if the pharmacist doesn't fill out the MUR/NMS forms correctly, not only will their employer lose what *used to be* script income, they could be removed from the register if any signatures were missing.

When will this nightmare end? Maybe when we get some senior people in the industry who have actually worked as pharmacists in the last decade? Is that really too much to ask? Or are we stuck with people from super discount supermarkets, and electrical retailers which make all of their money peddling useless extended warranties that you cannot claim on because they only cover you for acts of goldfish?

And yes, I have experience first hand of the "warranties" and my family and friends tell me the same things.

Pharmacy has so much to offer the public and other professions. We really do care about our patients and want to give the best outcome possible.

Somehow, I feel that more greedy, self-serving, and pompous people are yet to come.

Or maybe we will get a genuinely altruistic person who actually cares about patient outcomes, workforce well-being, and not how fast they can pay down the mortgage on the summer home in the Canary Islands.

History would suggest that I will only be disappointed. You spend all that time getting your name registered with the GPhC (5 years or 4 for us oldies), learning to put patients first, and treating everyone with dignity.

And yet, you spend your whole life over a barrel being forced to do things you don't agree with, so that someone you've never met can have a bet at a casino in Monaco.

Can I say something again please?

PATIENTS DO NOT WANT MURS OR SERVICES

GPS DO NOT WANT PHARMACISTS DOING THEM BECAUSE IT TAKES PART OF THEIR ROLE AWAY

PHARMACISTS DO NOT HAVE TIME TO PERFORM SUCH A ROLE IN ENOUGH DEPTH TO BE USEFUL

WHY ARE WE STILL BEING ASKED (FORCED) TO DO THEM?

GPhC please, please, please wake up and smell the cheese.

UK pharmacists are not here to pay for yachts in the Med, mansions in Zurich, and pensions for overweight ex-dentists. We are here to do good for the population. We are here to help other people, and not ourselves. I just wish everyone in the industry felt the same way. I just want to make peoples lives better and healthier, so stop forcing me to perform these pointless exercises.

Graham Pharmacist, Community pharmacist

Hi Mohmmed,

I bet they never mentioned remuneration in any shape or form to you at University, Mr.Patel? Am I right? Or that you could just leave school at 16, work for a few years in an electrical shop or hyper discount shop of sorts and then enter the UK pharmacy industry in a top job and be in control of all those buffoons who spent 4 years full time at university? You must be pretty ignorant to have not done any research, and even stupid if you think you could do better than anyone else.

Surely everyone who starts a pharmacy degree in the UK should be told on the first day that they would be better off stacking shelves at Iceland than working your socks off to spend the rest of your life oppressed by someone who is from Mothercare and doesn't know what Apixaban is.

With the right pitch you can make 400 quids a day selling icecreams from a van, so the strife we endure is totally unecessary.

Wolverine 001 , Pharmacist Director

Great response Mr Patel!!! How would you discuss Gliclazide in a MUR...!!! Just hilarious - errr you wont be discussing at this any more as MUR's will be scarpped!!!

Mohammed Patel, Community pharmacist

If MURs get scrapped, I will eat my turban. Once someone gets something for nothing it is very hard to go back again.

Mark Boland, Pharmaceutical Adviser

When you do an MUR you are doing NOTHING for NOTHING.

Mohammed Patel, Community pharmacist

Here's how you should discuss gliclazide in a *real-life* MUR:

- As quickly as you possibly can because there are customers outside the consultation room who are getting angry that they cannot buy Solpadeine Plus.

- As quickly as you possibly can because the area manager is trying to call you to see how many MURs you have done.

- As quickly as you possibly can because the store manager is requesting your attendance at a labour allocation meeting.

- As quickly as you possibly can because you need to do staff reviews

- As quickly as you possibly can because you need to answer that important email from the CCG

- As quickly as you possibly can because you need to submit service data

- As quickly as you possibly can because you have more than half a dozen patients waiting for their scripts to be dispensed. And they are looking seriously angry already!

- As quickly as you can because you need to conduct a back to work interview

- As quickly as you can because with MURs only QUANTITY counts. Nobody cares about what you say or what the outcome may be. Just do MORE!

- As quickly as you can because the building society is on the phone to ask why you have defaulted on your mortgage

Anyone seeing a pattern here?

Graham Pharmacist, Community pharmacist

Don't forget the fact that first of all no patient actually wants an MUR. So the only thing going through their head is "what can I do next time to avoid this seeing as I only spoke with my GP 20 minutes ago"? I must agree with your general sentiment, and am sure most of my friends would also. MUR is not fit for purpose, but then me thinks the GPhC is failing too. If some nepotistic croney scratches their back and tells them that they are doing a wonderful job, are we supposed to acept the fact that they are right and we are wrong despite the fact that they were inspected by people with a financial ineterest in giving them the maximum score?

I have seen the word corruption used in these comments and I can only agree with the feelings that the poster came up with. Loads of pharmacists seem to feel the same way up in the NE too.

Ilove Pharmacy, Non Pharmacist Branch Manager

You may have seen the word corruption then quickly see the post deleted by Waldron. Makes you wonder eh.....


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