Although the role of pharmacy is developing, there is still the opportunity for the profession to be more proactive in its use of diabetes management skills. FIT UK hopes to develop education resources to support pharmacists
Alia Gilani BSc (Hons) Pharm MPC IPres
Health Inequalities Pharmacist and member of the Forum for Injection Technique (FIT) UK
The Role of Pharmacists in Diabetes Care acknowledges the increasing European diabetes epidemic and the inevitably that, as the strain on the workload of doctors and nurses increases, alternative models and opportunities for diabetes care will be sought. Pharmacists have the potential to use their skills and contact with patients to support and manage diabetics. In the UK, the ‘independent prescriber’ qualification is available, as is a primary care Diabetes Diploma. The article considers the opportunities available to pharmacists, the need for the profession to be proactive, and the need for further resources and educational material.
Because populations are adopting a more obesogenic lifestyle, current trends indicate that the diabetes epidemic is increasing and will be a significant global burden in the future. More than 55 million people in Europe now have diabetes.(1) The outlook for the UK is similar: diabetes is increasing and future projections estimate a figure of five million diabetics by 2025.(2) The pattern of growth for diabetes will have an impact on all healthcare sectors by increasing morbidity and mortality trends. The economic burden of diabetes is significant; 10% of the National Health Service budget is being spent on diabetes, which amounts to approximately £9 billion annually.(3)
Doctors and nurses have historically been responsible for diabetes management and treatment; however, the rising diabetes epidemic will place an inevitable strain on their workload. Alternative models and opportunities for diabetes care will be sought, and this will result in an increased role for pharmacists.
Role of the pharmacist
The role of a pharmacist in the UK has long outgrown the historical one of advising and dispensing medicines. The UK Department of Health’s Choosing Health Through Pharmacy document depicted the Government’s desire to continue extending pharmacists’ services.(4) The 1999 Crown report recommended that pharmacists be given prescribing roles.(5) The initial qualification available to undertake was ‘pharmacist supplementary prescriber’ and this was superseded in 2006 by the ‘independent prescriber’ qualification, providing more autonomy. The ‘independent prescriber’ qualification allows pharmacists to run chronic disease medication review clinics with essentially the same prescribing authority as a general practitioner (GP).
Community pharmacists have increasingly been given the opportunity to have a greater clinical role and to move away from the traditional model of dispensing pharmacists. This has been reflected by the new service developments in the community pharmacy contract, which have established a role and provided financial incentive for pharmacists to undertake medication review. In England, this was the New Medicines Service and, in Scotland, the Chronic Medication Service.(6,7) Some community pharmacies have also been very proactive in focusing on the primary prevention of diabetes by offering free glucose testing.(8)
A pharmacist can arguably have greater contact with patients than can a GP. It is estimated that each adult visits a pharmacy 12 times annually.(9) This provides the opportunity to monitor diabetic patients more closely. Pharmacists can influence the effective use of medicines and are a vital link that can work in partnership with other healthcare professionals to best communicate care issues. Another example of pharmacists working closely with the multi-disciplinary team is pharmacists based in general practices. There are a paucity of studies that evidence the benefits of having general practice-based pharmacists in managing diabetes, however, there are positive outcomes shown when community‑based pharmacists manage diabetics.(10)
In secondary care, there is also a role for pharmacists in managing diabetes. The responsibilities of a hospital pharmacist include working closely with medical and nursing staff during ward rounds and ensuring that patients receive the most appropriate treatments in clinics. This also extends to prescribing, advising on the selection of medicines, and deciding the dose and route of administration for an individual patient.
In the UK, there are opportunities for pharmacists to equip themselves with educational support so that they can effectively manage diabetic patients. Aside from the independent prescribing qualification during which pharmacists can specialise in diabetes, it is also possible to undertake a primary care Diabetes Diploma. The diploma covers the basics of the condition including the signs and symptoms of diabetes, the medication used, target values for clinical surrogate markers, and management advice.
There are multiple diabetes care issues that pharmacists can address. This is achievable by concordance promotion, monitoring for adverse drug reactions, assisting diabetics with the self-management of glucose blood monitoring, promoting evidence-based prescribing, optimising therapies, monitoring clinical markers and referral to the wider health and social care team. Although the role of the pharmacist has evolved from its traditional image, there is further work required if pharmacists are to be considered as valuable as doctors and nurses in the management of diabetes. Currently, approximately 4% of UK pharmacists have acquired the independent prescribing qualification.(11) There are gaps in education that would support the better management of diabetes, such as in injection technique.
If further resources and educational material were to be available to pharmacists on the subject area of diabetes injection technique, then pharmacists, who for the most part, are easily accessible to patients, could disseminate this information to allow individuals to better self-manage their condition. One way of educating pharmacists in the area of injection technique would be to utilise the Forum for Injection Technique (FIT) UK. FIT would like to develop resources that benefit pharmacists as well as all others involved in diabetes care. Currently The First UK Injection Technique Recommendations 2nd Edition document, adapted and published by FIT, is available to download from the FIT website.(12) These recommendations aim to raise awareness of existing and emerging research relating to injection technique, and the impact this may have on health outcomes for those with diabetes that require subcutaneous injection therapy. The recommendations will be annually reviewed to include new evidence as it emerges.
Being a long-term condition, diabetes needs constant management and review. Injection technique is an incredibly important part of diabetes treatment. For the injectable therapies dispensed by pharmacists to work optimally, correct injection technique is essential. The recommended site for insulin and incretin mimetic injections is the subcutaneous tissue.(13) Injecting into the subcutaneous layer allows the insulin to be absorbed at a more predictable rate, which can result in better glycaemic control.(14)
Incorrect technique, including using the incorrect needle length and not rotating injection sites, can lead to these injectable therapies not being absorbed in a predictable manner, which can lead to problems such as hypoglycaemia and/or hyperglycaemia.(15,16) Other potential injection problems include lipohypertrophy (accumulation of fat under the skin caused by injecting too frequently in the same area) or bruising and bleeding at the injection site.
Further work needs to be undertaken to provide support for pharmacists who have the skills and opportunity to support and manage diabetics. Although the role of pharmacy has already developed to be more clinical, there is still the opportunity for the profession to be more proactive in its use of diabetes management skills. FIT UK hopes to develop diabetes education resources to support pharmacists. Inspiring confidence in this area will help pharmacists be at the forefront of diabetes care.
- The diabetes epidemic is increasing and more than 55 million people in Europe now have diabetes. This will place an inevitable strain on the workload of doctors and nurses and result in an increased role for pharmacists in diabetes care.
- The role of a pharmacist has outgrown the historical one of advising and dispensing medicines. The ‘independent prescriber’ qualification allows pharmacists to run chronic disease medication review clinics with essentially the same prescribing authority as GPs.
- Being a long-term condition, diabetes needs constant management and review. A pharmacist can arguably have greater contact with patients than a GP. This provides the opportunity to monitor diabetic patients more closely.
- If further resources and educational material were to be available to pharmacists on the subject area of diabetes injection technique, then pharmacists could disseminate this information to allow individuals to better self-manage their condition.
- The First UK Injection Technique Recommendations 2nd Edition document, adapted and published by the Forum for Injection Technique (FIT), is available to download from the FIT website. Further work needs to be undertaken to provide support for pharmacists who have the skills and opportunity to support and manage diabetics.
- International Diabetes Federation Europe. Diabetes at a Glance, 2012. www.idf.org/sites/default/files/EUR_5E_Update_Country.pdf (accessed 9 August 2013).
- AHPO diabetes prevelance model. http://bit.ly/aphodiabetes (accessed 9 August 2013).
- Khunti K, Kumar S (eds). Diabetes UK and South Asian Health Foundation recommendations on diabetes research priorities for British South Asians, 1st edn. Diabetes UK, London, UK;2009.
- Department of Health, Choosing health through pharmacy, 2005. http://bit.ly/13yuRZM (accessed 9 August 2013).
- Crown J. Review of prescribing, supply and administration of medicines. Final Report. London: Department of Health; 1999.
- Pharmaceutical Services Negotiating Committee.NMS, 2011. http://psnc.org.uk/services-commissioning/advanced-services/nms/ (accessed 9 August 2013).
- Establishing Effective Therapeutic Partnerships. A generic framework to underpin the Chronic Medication Service element of the community pharmacy contract. A report for the Chief Pharmaceutical Officer. The Scottish Government; 2009.
- Lloyds Pharmacy. Diabetes Testing. www.lloydspharmacy.com/en/info/free-diabetes-test.
- Department of Health. Choosing Health through pharmacy: a programme for pharmaceutical public health 2005–2015. London:Department of Health;2005.
- McLean D, Finlay A, McAlister MD et al. A Randomised Trial of the Effect of a Community Pharmacist and Nurse Care on Improving Blood Pressure Management in Patients with Diabetes Mellitus. Study of Cardiovascular Risk Intervention by Pharmacist-Hypertension (SCRIP-HTN). Arch Intern Med 2008;168(21): 2355-2361.
- General Pharmaceutical Council. Pharmacy workforce continues to become more diverse. http://bit.ly/ONhS9J (accessed 9 August 2013).
- FIT UK, The First UK Injection Technique Recommendations 2nd Edition; 2012 www.fit4diabetes.com/files/2613/3102/3031/FIT_Recommendations_Document.pdf (accessed 9 August 2013).
- Frid A. Fat thickness and insulin administration, what do we know? Infusystems Int 2006;5(3):17–19.
- Hofman PL et al. An angled insertion technique using 6-mm needles markedly reduces the risk of intramuscular injections in children and adolescents. Diabet Med 2007;24:1400–5.
- Polak M et al. Subcutaneous or intramuscular injections of insulin in children: are we injecting where we think we are? Diabetes Care 1996;19(12):1434–6.
- Birkebaek NH et al. A 4-mm needle reduces the risk of intramuscular injections without increasing backflow to skin surface in lean diabetic children and adults. Diabetic Care 2008;31(9):e65.