“Not so good, to be honest,” says Kathleen. “Those metformin tablets Dr Jakeman prescribed gave me terrible tummy trouble. When I told him, he said he would give me something different, but I think he’s made a mistake. Look.” Parveen sees that the prescription is written as ‘Metformin 500mg m/r tablets. Take one tablet once in the evening with food, increasing after two weeks to two tablets in the evening with food’. “I wouldn’t mind all the running to the bathroom if I knew it was working,” continues Kathleen, “but the doc says there is no point doing a blood test for another couple of months. Should I buy one of those home testing machines, do you think?”
In terms of pharmacological interventions, the GP is following the latest guidance published by NICE on the management of type 2 diabetes in adults. This states that a trial of modified-release metformin should be considered for anyone who experiences gastrointestinal side-effects with standard-release formulations of the drug.
Dr Jakeman is also sticking to the recommendations regarding measuring HbA1c, which NICE says should be taken at three to six monthly intervals until the level is stable, and then every six months thereafter.
Self-monitoring of blood glucose levels should not be routinely offered unless the person is pregnant (or planning to conceive), on insulin, taking oral antidiabetics that may increase the risk of hypoglycaemia while driving or operating machinery, or has experienced hypos in the past.
The updated NICE guidance includes a number of changes, in particular a reminder that healthcare professionals should adopt an individualised approach to diabetes care that takes into account the person’s preferences, co-morbidities, risks from polypharmacy, and ability to benefit from longterm interventions because of reduced life expectancy. Reassessing the patient’s needs and circumstances at every review is also emphasised – including evaluating whether any medicines should be stopped.
Of particular relevance to the community pharmacy team is the NICE recommendation to reinforce advice about diet, lifestyle and adherence to drug treatment, as this can make a substantial difference to glycaemic control.