Well now I have delivered an introduction to medicines optimisation in patients with diabetes. And here is the overview. If you have diabetes, let me know if it rings true. If you are a pharmacist, reflect and offer comments.
I recently met Professor Nick Barber of the famous ‘Barber’s boxes’ – a must read paper from the early 90s for every pharmacist and I listened to so much tosh about medicines optimisation to weep.
So in diabetes two worlds collide.
Pharmaceutical assessment of medicines for diabetes which seem to focus on just cost and efficacy. The current guidelines which start by advocating patient centred care and then are interpreted in a rigid way, supported by performance indicators and QoF. The main measure of efficacy is HbA1c lowering and I have sat listening to talks on £ per mol/L lowering.
And then there is the real world that the patient talks about and that brings in the rest of Barber’s boxes. After time spent talking to patients, I have concluded that patients have three goals:
They want to feel well again. Most patients with diabetes, just don’t feel right and we need to fulfil this goal as quickly as possible. It may not be easy in patients with chaotic lifestyles, co-morbidities and complications that have already set in. At the very least we should stabilise wellness for a while.
They want to get back some of their life. This has a lot to do with security and fear and requires considerable thought about treatment. We may be talking about the confidence to go out, to meet people, to eat with people. Hypoglycaemia has a significant impact on achieving this goal and make achieving this goal impossible. Think also about treatment progression and how changing treatments can cause great disruption. And specific symptoms that need specific attention.
They want to maintain their quality of life over their lifetime. If you arrive at discussing this goal, then this brings in every element of lifestyle and other treatments. It is a huge opportunity to introduce major changes that will really affect outcomes, but it does come through trust in achieving the first two goals. It also brings in FBG, PPG and HbA1c, which are your markers of success.
Taking these goals seqentially may take more time, but buidling the care package with the patient takes time and patience. Diabetes belongs to the patient. The patient is the main carer. And the patient is the only one that can achieve their goals. They just need our help and support.
So whether you are a pharmacist, a nurse or a doctor, take a second look at the medicines and ask whether they are the best to achieve the patient’ goals at this point in time.
When you advise on medicines think twice about what you are actually suggesting related to the patient goals mentioned above. It may not always be prudent to increase the metformin until you get indigestion, up the sulphonylurea until you feel unwell and have to nibble food constantly or drive up the insulin until hypoglycaemia make you scared to leave the house. With this treatment strategy it is no wonder that patients are non-complient and fail to reach HbA1c targets.
Medicines optimisation – it’s all about the patient.