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Royal Pharmaceutical Society UCL School of Pharmacy New Year Lecture 2019

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Diabetes and the Pharmacy Army
Philip Newland-Jones
Consultant Pharmacist Diabetes & Endocrinology
University Hospital Southampton NHS Foundation Trust

Publicada em: Tecnologia
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Royal Pharmaceutical Society UCL School of Pharmacy New Year Lecture 2019

  1. 1. Diabetes and the Pharmacy Army. Philip Newland-Jones Consultant Pharmacist Diabetes and Endocrinology
  2. 2. Type 2 diabetes is a progressive disease associated with weight gain Adapted from: Kendall D et al. Am J Med 2009;122:37–50 Weight gain Normal DiabetesNon-Diabetic Hyperglycaemia Diagnosis Time Hyperglycaemia Blood glucose Insulin Production Insulin resistance Beta Cell Function
  3. 3. Interventional Relationships Between Cholesterol, BP and HbA1c with CVD events(20) 119 44 34 0 50 100 150 NNT for 5 years in order to prevent 1 CVD event 0.9% reduction in HbA1c 1 mmol/L reduction in cholesterol 10/5 mmHg reduction in BP For each variable, data shown are for a change corresponding to the mean change of the variable in intervention studies BP=blood pressure; CVD=cardiovascular disease; NNT=number needed to treat 20. Adapted from Yudkin JS et al (2010) Diabetologia 53: 2079–85 https://link.springer.com/content/pdf/10.1007%2Fs00125-010-1864-z.pdf Accessed September 2017
  4. 4. MEDICINES
  5. 5. Drug choice in T2DM 2005 20171946 Diabetes drugs (date of first authorisation) 1. White JR, Diabetes Spectrum 2014; 27(2): 82-86 NPH insulin1 Acarbose1 Meglitinides1 TZDs1 SU drugs1 Metformin1 2006 Analogue prandial insulin1,6 Analogue basal insulin1-5 Internal use only. Not for distribution
  6. 6. Drug choice in T2DM 2017 1. White JR, Diabetes Spectrum 2014; 27(2): 82-86 First in class Follow-on drugs Biosimilar 2006 2008 2010 2012 2014 2016 2017 20171946 Acarbose1 Meglitinides1 TZDs1 SU drugs1 Metformin1 2006 Analogue prandial insulin1 Analogue basal insulin1 NPH insulin1 * = date of CHMP approval, Toujeo (Ref 4 ), Humalog 200 units/⌘ = fixed-dose combination Diabetes drugs (date of first authorisation) Analogue prandial insulin1,5,6 Analogue basal insulin1-4 DPP-4 inhibitor1, 10 DPP-4i + Metformin11-15 GLP-1 RA 1x/2x daily1, 7 GLP-1 RA + basal insulin21,22 SGLT-2 inhibitor1, 16 SGLT-2i + Metformin17-19 GLP-1 RA 1x weekly1, 8, 9 * * ⌘ ⌘ ⌘ DPP-4i + SGLT-2i20 U200 units/ml U300 units/ml Internal use only. Not for distribution
  7. 7. Long-acting Goal of insulin development: approach endogenous insulin secretion by healthy pancreatic beta-cells Future First clinical use of insulin 1922 Biosynthetic human insulin 1982 Rapid-acting insulin analogue 1996 Exubera inhaled insulin (withdrawn 2007) 2006 Afrezza inhaled insulin 2015 Short-acting 1950 NPH insulin 1953 Lente insulin 2000 Long-acting insulin analogue 2013 Degludec 2015 Biosimilar glargine U100 2015 Glargine U300 Smart insulin PEGylated insulin (discontinued) Fast-acting insulin aspart Recombinant insulin + EDTA Recombinant insulin + hyaluronidase BioChaperone lispro Trepostinil lispro Physiologically distributed insulin 1920 1940 1960 1980 2000 2014–2015 Ultra-fast-actingEDTA, ethylenediaminetetra-acetic acid; NPH, neutral protamine Hagedorn Adapted from Cahn et al. Lancet Diabetes Endocrinol 2015;3:638–52 Eli Lilly Patent Application 12 Nov 2015; Eli Lilly Press Release 4 Dec 2015; Novo Nordisk Capital Markets Day R&D update 19 Nov 2015
  8. 8. Treatment options in the management of type 2 diabetes BP: blood pressure; DPP-4: dipeptidyl peptidase-4; GLP-1: glucagon-like peptide-1; HDL: high density lipoprotein; LDL: low density lipoprotein; SGLT2: sodium-glucose co-transporter-2; TZD: thiazolidinedione; TG: triglycerides. 1. Adapted from Nathan DM et al. Diabetes Care. 2009;32:193–203; 2. Wulffele MG et al. J Intern Med. 2004;256:1–14; 3. Victoza (liraglutide) SmPC. Available at: https://www.medicines.org.uk/emc/medicine/21986 (accessed August 2017); 4. Jardiance (empagliflozin) SmPC. Available at: https://www.medicines.org.uk/emc/medicine/28973 (accessed August 2017); 5. Valentine V. Clinical Diabetes. 2012:30:151–155; 6. Phillips P et al. Diabetes Care. 2003;26:269–273; 7. Acarbose SmPC. Available at: https://www.medicines.org.uk/emc/medicine/27829 (accessed August 2017); 8. Kurukulasuriya LR. and Sowers JR. Cardiovasc Diabetol. 2010;9:45; 9. The Cochrane Collaboration. Meglitinide analogues for type 2 diabetes mellitus (review); 10. Prandin (replaginide)SmPC. Available at: https://www.medicines.org.uk/emc/medicine/18980 (accessed August 2017); 11. Inzucchi SE. et al. Diabetologia. 2012;55:1577–1596. Class HbA1c reduction1,4,6,9,11 Increased risk of hypoglycaemia1,4,7, 10 Weight change5,8,11 Effect on lipids8,11 Systolic BP change2,3,5 Metformin 1.0 – 1.5% X ↔ / ↓  Neutral Sulphonylurea 1.0 – 1.5%  ↑  Mainly in TG Not reported TZDs 1.0 – 1.5% X ↑  HDL and TG Not reported DPP-4 inhibitors 0.5 – 1.0% X ↔ ? Not reported GLP-1 agonists 1.0 – 1.5% X ↓  Reduction Long acting insulin 1.5 – 3.5%  ↑  Not reported Rapid acting insulin 1.5 – 3.5%  ↑  Not reported SGLT2 inhibitors 0.5 – 1.1% X ↓ ↑ HDL and LDL Reduction Acarbose 1.0% X ↓ ? ? Not reported Meglitinides 0.5 – 1.0%  ↔ ? ? Not reported
  9. 9. DATA
  10. 10. Comparator – HbA1c & MPG Diabetes Care 2008 (8) 1473-8
  11. 11. Blood Glucose Testing Time BGL’s(mmol/L) 4 12 20
  12. 12. Ambulatory glucose profile
  13. 13. PITFALLS WITH WEIGHT LOSS
  14. 14. Proietto MJA 2011;195:144–6 Central regulation of body weight αMSH, alpha melanocyte-stimulating hormone; AgRP, agouti-related peptide; CART, cocaine and amphetamine-regulated transcript; CCK, cholecystokinin; CRH, corticotropin-releasing hormone; GLP-1, glucagon-like peptide; MCH, melanin-concentrating hormone; NPY, neuropeptide Y; NTS, nucleus of the tractus solitarius; PP, pancreatic polypeptide; PYY, peptide YY
  15. 15. Very-low-calorie diet Modified diet plus behaviour therapy Very-low-calorie diet plus behaviour therapy Years after intervention 0 –5 –10 –15 –20 5 1Intervention 2 3 4 5 Weightchange(kg)Diet and behavioural intervention 0 Wadden et al. Int J Obes 1989;13 Suppl 2:39–46
  16. 16. DIABETES LANDSCAPE
  17. 17. NHS 10 year plan
  18. 18. • 3,689,509 Patients with diabetes • UnknownNumber of pharmacists working in diabetes • 1400+833 Nurses and doctors working in diabetes Diabetes UK. State of the Nation 2016 (England): Time to take control of diabetes. July 2016 British Medical Association. Survey of GPs in England. Nov 2016
  19. 19. Current Diabetes Workforce • 84% of GPs find their workload unmanageable • 78% of Diabetes Specialist Nurses (DSNs) are concerned that their workload is having an impact on patient care and/or safety • Can pharmacists help this situation? British Medical Association. Survey of GPs in England. Nov 2016 Diabetes UK. Diabetes specialist nursing workforce survey. 2016
  20. 20. UK Pharmacy and Diabetes Strategy • Pharmacy and diabetes workforce policy document in development • Royal Pharmaceutical Society (RPS), NHS England and key pharmacist leaders • Context: – GP workload – Diabetes specialist nurse numbers – Diabetes specialist medical consultants – Diabetes patient numbers – Diabetes patient complexity
  21. 21. The Development Pyramid
  22. 22. Diabetes Competence Framework ◎ Access via www.diabetes.org.uk (professional competencies) ◎ Key tool to planning your specialist portfolio ◎ Demonstrate competencies ◎ Action plan areas for development
  23. 23. RPS Professional Development Roadmap Royal Pharmaceutical Society. Professional development roadmap. 2016 Experience in diabetes NOT career in total
  24. 24. COMMUNITY PHARMACY
  25. 25. Community Pharmacists • Front line professionals • Accessible 7 days a week, up to 24 hours a day • Advice and practical help for short-term and long-term conditions • Clinical roles: monitoring of long term conditions, medicines use reviews, new medicines service • Essential in public health promotion; risk assessments, smoking cessation, diet and exercise, sexual health
  26. 26. Examples: Primary Care • Cornwall and Isles of Scilly LPC: Patient Activation Measures and motivational interviewing to improve self-management of T2DM • County Durham and Darlington LPC: Just Beat It! Is a support programme to help reduce diabetes risk through education and physical activity sessions • Essex LPC: Supporting changes to blood glucose meter supplies and providing free replacement meters • Hampshire and Isle of Wight: Opportunistic identification of patients and brief intervention on footcare. Deliver simple educational messages and advice on self-care and raise awareness of deterioration • Hertfordshire LPC – Community Pharmacy Diabetes Plus: education provided to pharmacists to support patients with information “top up’s” early in diagnosis Pharmaceutical Services Negotiating Committee. Services database. September 2018.
  27. 27. GP PRACTICE
  28. 28. GP practice pharmacists • London AT Medics: – 8 care processes achieved on 86% of patients – Triple target reached by 47% – Variation reduced from 82% to 30% across the practices • Devon SOAR medical: – Low spend and poor outcomes – Project to standardize approach by practice based pharmacists across 12 GP practices
  29. 29. HOSPITAL
  30. 30. • Peri-operative optimization • Education of ward based pharmacists • Review of high risk pescribing • Adequate, timely medication history taking • Alerts to pharmacist to review patient • Improve access to self administration
  31. 31. Pharmacy Technicians
  32. 32. Consultant Pharmacist Job Plan • 10 sessions (half a day) – 6 clinical (was 5 but short on medical staff currently) – 2 education and training – 1 strategy and leadership – 1 research • Rotation of clinical activity on consultant Rota – Ward rounds/ Foot clinic / Vascular MDT / Insulin Pump Clinic / Complex Diabetes Clinic / Post Discharge Clinic / Young persons Diabetes Clinic / Concentrated insulin clinic / Endocrine clinic / Lipid Clinic + referrals for paediatric type 2 diabetes
  33. 33. Internal Assurance of Autonomous working • 3 monthly peer review of 3 cases for whole team • 360 degree feedback from colleagues every 3 years for revalidation • 10 patient anonymous questionnaires yearly • Annual Clinical Consultant Appraisal as well as professional appraisal • Usual Continuing Professional Development (CPD)
  34. 34. In summary Well placed Pharmacists are present to help at every stage of the diabetes story Skills We know how to balance efficacy, safety, monitoring and disease management Knowledge Understand medicines optimisation and treatment individualisation and how to use these to empower patients Evidence Emerging evidences changes the choice before guidelines can be updated. Cost Newer medicines or mechanisms of glucose testing may be more expensive, but could achieve more in the long run Choices We have the opportunity to advise and influence treatment choices and support patients to voice their opinion

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