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Diabetes Diabetes is a

Diabetes Diabetes is a condition in which the body fails to produce enough insulin to keep blood glucose (sugar) levels in the normal range. Insulin is a hormone that is produced by special cells (called beta cells) in the pancreas. Insulin facilitates the entry of glucose into muscle, adipose (fat) and several other tissue types, where it can be used for energy, and also switches off the release of glucose by the liver. Glucose comes from the carbohydrates we eat, and is present in the blood as an energy source. Glucose also comes from the liver, where it is stored in order to provide a constant supply for when we are not eating. In people without diabetes, insulin keeps blood glucose levels fairly stable (between 4.0mmol/L and 7.5mmol/L). In people with untreated diabetes, blood glucose levels can regularly go dangerously high (11mmol/L and higher). There are three different types of diabetes. Type 1 diabetes Type 1 diabetes is most commonly diagnosed in children aged seven to 12 years, although it can occur at any age. It is an autoimmune condition where the immune system of the body rejects or destroys its own insulin-producing cells. People with type 1 diabetes produce very little or no insulin hormone, resulting in a life-long dependence on exogenous insulin. It is unknown what first starts this cascade of immune events, but evidence suggests that both a genetic predisposition and environmental factors, such as a viral infection, are involved. Of all the people with diabetes about 10% of them have type 1 diabetes. Symptoms include excessive or constant thirst (polydipsia), excessive and frequent urination (polyuria), tiredness or weakness and mood changes. People with type 1 diabetes often experience rapid weight loss because their body is actually being starved. Some people may also have abdominal pain, nausea or vomiting, skin infections (such as thrush), extreme hunger or have difficulty concentrating. Symptoms usually develop quickly and urgent hospitalisation may be necessary. Diagnosis of type 1 diabetes is by blood and urine tests, and treatment is with multiple daily injections of insulin or a continuous insulin pump. Lifestyle changes are usually necessary and insulin treatment may need to be managed around sport and eating times. Type 2 diabetes This is the most common type of diabetes and usually affects people who are middle-aged or older, although can occur earlier in people who carry excess weight, do limited exercise, or of certain ethnicities. Unlike people with type 1 diabetes, people with type 2 diabetes produce insulin; however, it is either not enough to mop up all the glucose in the blood or their body is unable to recognise the insulin and use it properly (insulin resistance). Type 2 diabetes comes on gradually and symptoms may be so subtle that many people are unaware that they have the condition. In addition to feeling thirsty and going to the toilet often, people with type 2 diabetes get tired, feel hungry and lack energy. Other common symptoms include more frequent infections and infections which are hard to heal, and some may have noticed a deterioration or blurring of their vision. Some people are able to manage their type 2 diabetes by altering their diet and losing weight. Most people will need to take oral medicines which stimulate the production of insulin or help cells uptake glucose. Many eventually require insulin injections as the disease progresses. About one-third of people with type 2 diabetes also have hypertension (high blood pressure) and dyslipidaemia (see also Heart Health). This combination of conditions is often referred to as “the metabolic syndrome". Diabetes in pregnancy (gestational diabetes) Gestational diabetes happens when a pregnant woman cannot produce enough insulin to cope with her body’s increased needs during pregnancy (a pregnant woman’s insulin needs are two to three times that of someone who is not pregnant). It affects around 4%–8% of pregnant women, and is routinely screened for during pregnancy at around 26 to 28 weeks’ gestation. In most cases, gestational diabetes is able to be managed by diet and exercise during the pregnancy; however, some women will require insulin injections. It usually disappears after the baby is born. Women who have had gestational diabetes are at greater risk of developing type 2 diabetes later in life. Long-term complications of diabetes When sugar levels in the blood remain high for a long period of time, permanent damage can occur to most of the blood vessels in the body, leading to an increased risk of heart attack and stroke, erectile dysfunction, foot problems, gum disease, infections, kidney disease, nerve damage and visual problems. Initial assessment for risk factors There are certain factors that increase the risk of type 2 diabetes, although not everybody with these risk factors goes on to develop the disease. Type 2 diabetes is more common in people who are overweight – especially if the extra weight is around the waist; in those who are inactive; and in people of an older age. Maori, Asian, Middle Eastern or Pacific Island people tend to develop type 2 diabetes at a younger age than those of European descent. People with a family history of diabetes or women who had gestational diabetes or gave birth to baby A part of your everyday. New Zealand’s premier pharmacy website keeping you up to date between issues. Page 56 HEALTHCARE HANDBOOK 2017-2018 Common Disorders

CONTINUING OTC EDUCATION weighing more than 4kg are also more likely to develop the condition. Some over-the-counter medicines such as NSAIDs (for example, ibuprofen) and sugar-containing cough syrups may not be suitable for people with diabetes. If you don't know the medical history of the customer, and they have obvious risk factors for the disease, tactfully ask if they have any known medical conditions or have ever been tested for diabetes. Refer anybody with suspected diabetes to a pharmacist. Screening for diabetes Doctors may order a glycated haemoglobin (HbA 1C ) test if they suspect diabetes. The test indicates how good a person's long-term blood glucose control has been and has less biological variability than a fasting plasma glucose (FPG) test. It also does not require fasting. However, FPG remains a valuble test. Range for HbA 1C An HbA 1C of greater than or equal to 50 mmol/mol is considered the threshold for the diagnosis of diabetes by the New Zealand Society for the Study of Diabetes (NZSSD) and the Ministry of Health. In people with symptoms (eg, polyuria, polydipsia), a single HbA 1C of >/=50 mmol/mol is considered diagnostic of diabetes for the majority of people (some exceptions exist). In people without symptoms, an HbA 1C of >/=50 mmol/mol strongly indicates diabetes; however, a second test (ideally another HbA 1C at least three months later or FPG) is needed for confirmation. Lifestyle interventions should be encouraged during the three-month wait for a second test. Home blood glucose testing Home blood glucose testing allows customers with diabetes to better manage their diabetes at home. If your pharmacy offers a blood glucose testing service your standard operating procedure (SOP) should clearly outline how to conduct the test and when to refer people to a doctor for an HbA 1C . Hyperglycaemia (high blood glucose) Customers reporting frequent high blood sugar readings (hyperglycaemia) should be referred to their doctor for further investigation. Reasons for high blood glucose recordings in known diabetics include increased carbohydrate intake, inadequate diabetes medicine or insulin, illness or decreased exercise. • ketones on the breath (fruity, acetone smell) • confusion, an alteration in consciousness or unconsciousness. People with diabetes who are sick may have difficulty managing their blood glucose levels, especially if they do not feel like eating. This can place them at risk of DKA or HHS. Advise people with diabetes to discuss with their doctor a “sickday plan” which details what changes to make to their insulin regimen and how frequently to measure their blood glucose. Hypoglycaemia (low blood glucose) Low blood glucose levels (usually less than 4mmol/L) in a diabetic may indicate the dosage of their diabetes medicine or insulin is too high or that a meal has been missed. Symptoms of hypoglycaemia include blurred vision, sweating, feeling lightheaded, confusion, trembling, tingling fingers and lips, and loss of consciousness. Management of suspected hypoglycaemia includes giving simple sugars (two to three glucose tablets, half a glass of fruit juice, two to three teaspoons of jam, honey or sugar in water, seven to eight jelly beans) every 10 minutes until the blood glucose reading is satisfactory. Follow with a meal or complex carbohydrate (slice of bread, piece of raw fruit, two crackers or biscuits). If a person has lost consciousness consult a doctor immediately. Advice for customers Ensure customers: • Know how to use their blood glucose meter and to contact a pharmacist or diabetes educator if the equipment is not working correctly. • Wear a personalised medical bracelet (eg, Bupa, Mediband, MedicAlert). Funded blood glucose meters NAME OF METER TYPE OF STRIP USED NOTES CareSens N CareSens N Strip Requires no coding CareSens N POP CareSens II CareSens Strip Requires manual coding AccuChek Combo FreeStyle Optium Sensocard Plus Talking Meter AccuChek Performa Test Freestyle Optium SensoCard Test Strips Only fully funded for people already using prior to 1 June 2012 Only subsidised for the severely visually impaired Hyperglycaemic emergencies Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS) are acute and potentially life-threatening complications of hyperglycaemia that can occur with either type 1 or type 2 diabetes. Both require urgent medical attention. Symptoms of DKA and HHS are generally preceded by a few days of unwellness but may develop suddenly and include: • signs of dehydration (thirst, dry mouth, lack of skin elasticity) • abdominal pain, nausea and vomiting, polydipsia • deep and laboured breathing Page 57

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