Introduction

Currently over 14 million people in the United States suffer from diabetes mellitus, the third leading cause of death by disease in the country. It can be associated with nephropathy, neuropathy, and retinopathy, as well as cardiovascular complications. Since incidence increases with age, the number of those afflicted only stands to rise as the elderly population in the U.S. continues to increase. The costs of diabetes care, already in excess of 20 billion dollars in 1987, also continue to rise as health care costs increase. With proper blood glucose control and preventive care, many of the complications associated with diabetes can be reduced.1 By assuming the role of patient educator and counselor, the pharmacist can create a niche in the health care delivery system in the management of patients with diabetes.

CAUSES AND SYMPTOMS

Diabetes mellitus is a disorder manifested by hyperglycemia. Patients with diabetes mellitus demonstrate an inability to produce insulin in sufficient quantities to meet the metabolic requirements of the body.2 Diabetes mellitus is generally categorized as one of two types: type I diabetes, insulin-dependent diabetes mellitus (IDDM), or type II diabetes, non-insulin-dependent diabetes mellitus (NIDDM).

Type I: Approximately 10-15% of those with diabetes mellitus have IDDM.1 The onset of IDDM usually occurs during childhood or adolescence. It is caused by an absence of endogenous insulin due to the autoimmune destruction of the pancreatic beta cells.2 The beta cell destruction may be caused by several factors:

The IDDM patient generally exhibits polyuria, polydipsia, and polyphagia as symptoms. Despite the increased food intake, IDDM patients usually lose weight because the lack of insulin prevents the body from using nutrients. The patient also appears fatigued, and experiences glycosuria and ketonuria. If these symptoms are unrecognized or untreated, the patient may develop diabetic ketoacidosis.1,2

Type II : Patients with NIDDM comprise 85-90% of those with diabetes mellitus. Patient age at onset is usually 35 years old or older. Up to 90% of the patients with this type of diabetes are obese. NIDDM is characterized by multiple defects in the pancreas, liver, and peripheral tissues. Since plasma insulin levels of the NIDDM patient are often normal or even elevated, many investigators believe that tissue insensitivity to insulin (rather than insulin deficiency) plays an important role in the development of NIDDM. As with the IDDM patient, those suffering from NIDDM may exhibit fatigue, polyuria, polydipsia, and polyphagia. Other symptoms include blurred vision, frequent infections, and pain and/or numbness in the extremities.1

TREATMENT

As the name implies, IDDM patients require exogenous insulin to function. A diet and exercise program may also be implemented to help control the diabetes.

For most NIDDM patients,diet and exercise alone will control the diabetes. If these methods are not effective, oral hypoglycemic agents and possibly insulin may be utilized.

THE ROLE OF THE PHARMACIST

In both types of diabetes, monitoring and education are very important. Since the pharmacist is perhaps the most accessible member of the health-care team, it is imperative that he or she act as a resource for the diabetic population. Many people with diabetes are unaware that they have the disease, so the pharmacist can play an important role by increasing public awareness of the risk factors of diabetes, particularly NIDDM.3

SELF-MONITORING OF BLOOD GLUCOSE

The management of diabetes has been made significantly easier for the patient with the advent of self-monitoring technology.4 Portable, lightweight glucose meters allow the patient to become directly involved in his or her own diabetes care. Self-monitoring of blood glucose requires the patient to obtain a capillary blood sample (by using a lancet device) which is placed on a test strip. Some of these test strips can be read visually. This can become a problem, however, as many diabetics experience visual difficulties due to their disease. Other strips are designed to be used in conjunction with the portable electronic meters. When used properly, glucose meters can provide highly accurate readings of blood glucose levels. Pharmacists should be prepared to help the patient select a meter that meets their needs, as well as to give instructions on proper operation of the machine.3 The following program outlines the use of two such glucose meters, the One-Touch Basic and the Accu-Chek Easy.

1 Campbell, S. "Diabetes:Recognizing Symptoms, Preventing Complications". Am Pharm. May 92; NS32:38-42.

2 Woodley, M. and Whelan, A. (Eds.) The Washington Manual. 27th ed. Boston: Little, Brown, 1992.

3 Ponte, C. "Monitoring Diabetes Mellitus: The Pharmacist's Role". Am. Pharm. Jan 92; NS32:61-65.

4 White, J. "The Diabetes Control and Complications Trial and the Pharmacist". N.A.R.D. Journal. November 93; 25-27.

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