Diabetes and the Pharmacy Army
Philip Newland-Jones
Consultant Pharmacist Diabetes & Endocrinology
University Hospital Southampton NHS Foundation Trust
Use of FIDO in the Payments and Identity Landscape: FIDO Paris Seminar.pptx
Royal Pharmaceutical Society UCL School of Pharmacy New Year Lecture 2019
1. Diabetes and the
Pharmacy Army.
Philip Newland-Jones
Consultant Pharmacist Diabetes and Endocrinology
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. 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
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. 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. 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. 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
19. • 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
20. 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
21. 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
24. 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
25. RPS Professional Development Roadmap
Royal Pharmaceutical Society. Professional development roadmap. 2016
Experience in
diabetes
NOT career
in total
27. 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
28. 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.
30. 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
32. • 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
34. 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
35. 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)
36. 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
Main talking point
Prevention of cardiovascular disease is a key aim in the management of risk factors in type 2 diabetes. Before looking exclusively at the effects of HbA1c control, this slide provides an overview of the interventional relationships between HbA1c, cholesterol and blood pressure and the prevention of cardiovascular disease events. While this comparison might suggest that glucose control is less important than managing cholesterol and blood pressure, it should be remembered that the management of type 2 diabetes is about more than cardiovascular considerations alone.
Speaker notes:
Presentation to focus on regular “human” insulin, fast-acting insulin analogues and ultra-fast-acting insulin analogues
Another important development was insulin pumps for CSII in the 1980s
In addition to the development of ultra-fast-acting insulins; another important research area is the closed-loop artificial pancreas system
Reference:
Feher & Bailey. Reclassifying Insulins. Br J Diabet Vasc Dis 2004;4(1).
HbA1c compared with mean plasma glucose
Slide
Ask:
Would you prefer to be patient a) [BLUE dots] b) [yellow dots] c) [RED dots]
What if I were to tell you this were the same patient on the same day? Capillary glucose levels are snapshots of glucose levels, they tell you nothin more or less than what is happening to the glucose at the time you take it.
Obesity is now recognised as a chronic disease that requires long-term medical management to achieve sustained weight loss and decrease associated morbidity and mortality. While short-term weight loss is readily achieved with diet and exercise, most individuals are unable to maintain the weight loss for an extended period. Avoiding weight regain is usually a challenge because physiologic mechanisms, some poorly understood, promote weight regain. Up to 75% of dieters, especially people on very low calorie diets (400-800 kcal/day) regain much of the lost weight within 1 year.22
As weight loss objectives are often not achieved through diet and behaviour modification alone, there remains a need for more efficacious approaches. An extensive study program has shown that Xenical, when used in conjunction with a mildly hypocaloric diet, produces significant weight loss, reduced weight regain, improvements in the comorbidities associated with obesity and an improved quality of life compared with diet alone.