Diabetes has, for some time, been considered an epidemic. The International Diabetes Federation estimates that by 2040, one in 10 people globally will have the condition.
Type 2 diabetes is the most common form. The chances of developing it increases with age, and it is also associated with obesity. People over 40 years old are more likely to be diagnosed, however it is becoming more common in children, adolescents and younger adults.
One in 16 people in the UK are believed to have diabetes, including around 750,000 people estimated to be living with the condition undiagnosed. Depending on the reference source, it is also estimated that type 2 diabetes accounts for 85-95% of all cases.
When providing a medicines use review (MUR) to patients with type 2 diabetes, it is important to remember that they are up to five times more likely to have cardiovascular (CV) disease than the general population, and two to three times more likely to die as a result of a CV complication.
What is type 2 diabetes?
Type 2 diabetes occurs when the hormone insulin, produced by beta cells in the pancreas, is inadequate to maintain normal blood glucose levels; or where the body is unable to use the insulin the pancreas produces – known as insulin resistance.
There are many risk factors which have been linked to developing type 2 diabetes, including:
- being overweight or having a high body mass index
- having a large waist – more than 80cm in women, 94cm in men or 90cm in South Asian men
- having an African-Caribbean, Black African, Chinese or South Asian background and being over 25 years of age
- being over 40 years of age (if from any other ethnic background)
- having a parent or sibling with diabetes
- having had high blood pressure, a heart attack, a stroke, polycystic ovaries or gestational diabetes
- giving birth to a baby weighing more than 10lb (4.5kg)
- having schizophrenia, a bipolar condition, depression or taking antipsychotic medication.
Treatment for type 2 diabetes aims to keep blood glucose levels as close to normal recommended levels as possible to prevent further health problems developing. Once diagnosed, a patient will usually attend regular reviews with their healthcare team, or they may be referred to a hospital-based diabetes team.
Patients diagnosed with type 2 diabetes should have glycated haemoglobin (HbA1c) urine tests at least twice a year. This test gives an indication of how well-controlled their diabetes is, by providing an average of blood glucose levels over the last few months. Results can be used to decide whether current treatments are controlling blood glucose levels effectively, or if a change in medication is required.
In some cases, insulin is given to type 2 diabetics where glucose-lowering medication is not effective.
In rare circumstances, transplants of pancreas or islet cells (which contain beta cells) may be carried out.
Table 1: Medicines used to manage type 2 diabetes
Routinely used first line to reduce the amount of glucose released into the blood and improve cell response to glucose
Increase the amount of insulin produced by the pancreas
Glibenclamide, gliclazide and glimepiride
‘Glitazones’ make cells more responsive to insulin, increasing glucose uptake
Prevent the breakdown of GLP-1, a hormone which helps the body produce insulin in response to high blood glucose
DPP4-inhibitors (linagliptin, saxagliptin and sitagliptin)
Injectable treatment designed to produce more insulin in response to periods of high glucose
Exenatide and liraglutide
Slows glucose production from digestion of carbohydrates
Nateglinide and repaglinide
Stimulate the release of insulin from the pancreas
Common concomitant medicines
High mortality rates exist with CV diseases – including heart disease, heart attack and strokes – linked to type 2 diabetes and diabetic kidney disease. Preventative medication for these conditions may include:
- low-dose aspirin
Patients may ask about alternative therapies, such as:
- Chinese traditional medicine and acupuncture
- dietary supplements
It is useful to be aware of these should a patient ask, although western health experts are sceptical about their efficacy.
Discussing lifestyle advice in an MUR
Healthy living is important to all people, but can play a vital role in those living with diabetes. Patients who take on board advice about a healthy and balanced diet can greatly improve their prognosis.
Patients diagnosed with type 2 diabetes may be offered access to a dietician who will give information and advice on which foods are best suited to them. You can use an MUR to check the patient understands their dietary advice and that they are following it.
Some key points to discuss in terms of diet are:
White and brown carbohydrates (such as rice, pasta and bread) – patients should be encouraged to switch all ‘white’ carbs to ‘brown’ varieties. Brown carbohydrates – usually wholemeal – provide a stable rate of glucose entering the blood stream during digestion, whereas white carbs cause sharp spikes and drops in blood glucose.
Sugar – When a patient is trying to control the amount of glucose in their blood stream it is important to maintain a low sugar diet. Ideally, they should eat mostly sugar-free or “no added sugar” foods. This is particularly important for snack items.
Salt and fats – Saturated fats increase the risk of CV problems and should always be consumed in low moderation. Use the MUR to explain the benefits of cutting out added salt completely, but also suggest substitutes with reduced sodium levels – such as LoSalt – to those patients who refuse to remove salt from their diets.
Fibre – Eating foods high in fibre helps people feel fuller, so they may eat and snack less. It also helps the digestive system to function and remove waste products from the body.
Water – Staying hydrated by having a good fluid intake helps many bodily processes, is good for kidney health, and gets rid of waste products.
- Exercise – Diabetic patients should exercise to ensure they have healthy circulation and improve their CV health.
- Smoking – Patients should be offered help to quit if appropriate.
- Alchohol – Advice on alcohol and typical units of consumption (14 units a week for both men and women) may help reduce alcohol-related complications, such as unexpected fluctuations in blood glucose levels.