Download Undiagnosed type 2 diabetes: recognise risk factors

medication review
The articles in this series are independently researched and compiled by PSA commissioned authors and peer reviewed.
Undiagnosed type 2 diabetes:
recognise risk factors
Continuing Professional Development
By Dr Shane Jackson
Learning objectives
After reading this article you should
be able to:
• Recognise risk factors for type 2
diabetes
• Recognise signs and symptoms
of type 2 diabetes
• Describe the diagnostic pathway
for diabetes
• Discuss the possible risk of
diabetes and weight gain with
antipsychotic drugs
• Recognise best practice
management of diabetes.
Competency standards (2010)
addressed:
7.1.1, 7.1.2, 7.1.3, 7.2.3
Accreditation number:
CAP110909f
Case study
Ms CW is a 55-year-old female
resident of a rural aged care facility.
She has the following medical
conditions:
• Mild intellectual disability
• Epilepsy
• Depression
• Back pain
• Hypertension.
Ms CW takes the following
medications:
• Clonazepam 1mg twice a day,
reduced two months ago from 2 mg
twice a day.
• Risperidone 0.5 mg at night
commenced about six months ago
• Ostevit D (cholecalciferol 1,000 IU)
daily commenced 12 months ago –
she refuses calcium supplements
• Perindopril 4 mg daily
• Oxcarbazepine (Trileptal) 600 mg
twice a day
• Paracetamol 500 mg, 1–2 tablets
four times a day when necessary
(frequency of use about twice a day)
• Esomeprazole 20 mg daily
• Folic acid 5 mg daily
• Escitalopram 20 mg daily.
Vol. 30 – September #09, 2011
Patient concerns
Shane Jackson is a community pharmacy
proprietor of two community pharmacies in
Tasmania and is also a consultant pharmacist
who performs medication reviews in aged
care facilities.
778
Ms CW’s main concerns with regards
to her health seemed to be increasing
frequency of urination. There were
also complaints of increasing urinary
tract infections (UTIs), with four
separate bouts of UTIs being treated
with trimethoprim 300 mg daily for
one week in the past five months.
Ms CW’s current weight sits at
116 kg and this has increased by
11 kg over the past two years. Her
last blood pressure when taken by
the nursing staff was 155/60 mmHg
and the previous one before that was
150/80 mmHg.
Ms CW indicated that her pain
is relatively well controlled with
paracetamol when necessary. She has
little, if any problems with reflux or
indigestion since she was commenced
on esomeprazole. According to her,
she has not had any seizures for some
time. When asked about her mood
she says she feels fine, especially
since the dose of escitalopram was
increased a year or so ago. She is
concerned about who is going to
help her when her mother passes on
(her mother also lives at the facility).
She was also concerned about how
well her mother was travelling with
her diabetes.
Some specific pathology tests
results were:
• Vitamin B12 224 pmol/L
(>150 pmol/L)
• Sodium 137 mmol/L
(135–145 mmol/L)
• Potassium 4.5 mmol/L
(3.5–5.1 mmol/L)
• Creatinine 64 micromol/L
(44–80 micromol/L)
• Hb 132 g/L
(115–165 g/L)
• MCV 91 fL
(80–100 fL)
Vitamin D 39 nmol/L (>75 nmol/L)
prior to replacement therapy
Upon discussion with the nursing staff
regarding Ms CW they indicated that
she is irritable and unsettled at times
and that is why the doctor started
risperidone. The nursing staff did not
cite any specific concerns about Ms
CW apart from her wandering around
the facility and constant questioning
Submit your answers online at www.psa.org.au and receive automatic feedback
to better care for this resident. In
addition, the use of clonazepam could
be reviewed. She has tolerated a
dose reduction in the past without
recurrence of seizures and further
dose reductions could be considered
with modification of the oxcarbazepine
dose if required. Benzodiazepines
have significant adverse effects
including excessive sedation,
confusion, falls and can also increase
the risk of agitation and depression.
Drug related problem
Inappropriate use of psychotropic
medication and diabetes as a
possible side effect of antipsychotic
drug therapy.
Ms CW appears to have a number
of symptoms that may indicate
possible diabetes. In addition to the
symptoms she also has some risk
factors that may increase the risk of
developing diabetes.
Inappropriate use of psychotropic
medication use in aged care facilities
has been an ongoing problem with
multiple studies showing a high rate
of benzodiazepine and antipsychotic
use in aged care facilities.1–4 Previous
Tasmanian research has shown
that the prevalence of antipsychotic
and benzodiazepine use in aged
care facilities was 21% and 43%
respectively.3 These medications
are often used (sometimes
inappropriately) to manage behavioural
problems associated with dementia
(BPSD), to treat anxiety and to
assist with sleep disorders. These
medications continue to be used in
aged care facilities despite well‑known
problems with falls, increased
risk of cerebrovascular events and
cognitive problems.5,6
In 2003, the FDA requested that
additional warnings needed to be
provided about the risk of diabetes
with the use of risperidone.7
Lambert, et al.9 in 2007, identified
that risperidone had a similar risk of
causing diabetes as olanzapine and
increased the risk of developing new
onset diabetes by 1.6 compared to
haloperidol.9 There have also been
reports suggesting no link about a
possible link between risperidone
and diabetes, although weight gain
has been shown with risperidone in
these studies.10,11 In Ms CW’s case,
because of a potential link between
the development of diabetes, her
weight gain and the inappropriate use
of this agent, the risperidone should
be ceased and her blood glucose level
should be monitored accordingly.
New-onset type 2 diabetes
The Australian national prevalence
study, AusDiab (the Australian
Diabetes, Obesity and Lifestyle
Study), showed that type 2 diabetes
affects 7.4% of the Australian
population in people aged 25 years
or older and that there is one
undiagnosed for every diagnosed
person with type 2 diabetes.12 Case
detection provides an opportunity
to identify the estimated 500,000
Australians with undiagnosed
type 2 diabetes.12
The AUSDRISK tool
(www.health.gov.au) is used to
identify those patients at high risk
of having pre-diabetes or type 2
diabetes.13 Using this tool, Ms CW
was identified at being at high risk
of developing diabetes (score of 17)
and this means that one in every
Other high risk categories for type 2
diabetes include the following:14
• People with impaired glucose
tolerance, and/or high impaired
fasting glucose.
• Aboriginal and Torres Strait
Islanders aged 35 and over.
• Certain high-risk non-English
speaking background people
aged 35 and over (specifically
Pacific Islanders, people from the
Indian subcontinent, people of
Chinese origin).
• People aged 45 and over who have
one or more of the following risk
factors:
– Obesity (BMI ≥30 kg/m2 as
an indicator)
– Hypertension
• All people with clinical
cardiovascular disease (myocardial
infarction, angina, stroke or
peripheral vascular disease).
• Women with polycystic ovarian
syndrome who are obese
(BMI ≥30 kg/m2 as an indicator).
In conjunction with the nursing
staff a fasting capillary glucose
level was taken and the result was
10.2 mmol/L. The oral glucose
tolerance test is not necessary
for every individual to confirm a
diagnosis of diabetes and may be
used in cases where there is an
equivocal result.
The diagnosis of diabetes is made in
the following ways:14
• Symptoms of diabetes (see Box 1)
and a random (non fasting) blood
glucose >11 mmol/L
• Fasting plasma glucose
≥7.0 mmol/L
• 2-hour plasma glucose >11 mmol/L
during an oral glucose tolerance
test (OGTT)
779
Vol. 30 – September #09, 2011
In Ms CW’s case it appears that there
is no clear indication for the use of
risperidone and that this is being
used to manage behaviours that
the nursing staff find troublesome.
Antipsychotic medications are
associated with significant adverse
effects, such as an increase in
mortality compared to placebo
(mostly due to cardiovascular events
(e.g. heart failure, sudden death) or
infections (e.g. pneumonia).7 Other
side effects include somnolence,
gait disturbance, urinary incontinence,
aggression and confusion.8 Given the
consequences of using antipsychotic
medication it would appear that the
risperidone should be ceased and
the nursing staff should manage any
behavioural concerns that Ms CW has
with diversional techniques. In this
case, the diversional therapist from
the facility was asked to develop a
program to assist the nursing staff
seven patients will develop diabetes
with this score. The Australian Type
2 Diabetes Risk Assessment Tool
was developed by the Baker IDI
Heart and Diabetes Institute and is a
validated tool that is useful for health
professionals to use to inform and
risk stratify patients for diabetes.
The Management of Diabetes in
General Practice Guidelines suggest
that asymptomatic people at high
risk of undiagnosed diabetes should
be identified and screened by
measurement of plasma glucose.14
Continuing Professional Development
of care staff about what they were
doing. They also said she is not very
compliant with good dietary practices
and they believed this was the reason
behind her weight gain. They indicated
that Ms CW and her mother are often
found eating lollies and chocolates
after they go on outings. A practising
dietitian has not seen Ms CW or
her mother since they have been at
the facility.
medication review
The articles in this series are independently researched and compiled by PSA commissioned authors and peer reviewed.
Box 1. Symptoms of diabetes
Vol. 30 – September #09, 2011
Continuing Professional Development
•
•
•
•
•
•
•
•
•
•
•
•
Excessive thirst
Polyuria
Tiredness and lethargy
Hunger
Slowly healing wounds
Increased infections
Blurred vision
Weight gain
Mood abnormalities
Headaches
Dizziness
Leg cramps.
– Blood pressure – noting her target
to minimise complications from
diabetes (target <130/80 mmHg).
In Mrs CW’s case an increase
in her dose of perindopril may
be necessary as ACE inhibitors
and angiotensin II receptor
antagonists have a beneficial
effect on reducing cardiovascular
and renal complications of
diabetes.15 (See below for
hypertension management steps)
– Review immunisation status
(influenza and pneumococcal)
and ensure they are up to date.15
– Optometrist or ophthalmologist
review.15
In Ms CW’s case, the risk factors
and the finding of a random BSL
measurement of 10.2 mmol/L it is
possible that she has developed
diabetes given her symptoms and risk
factors. Recommendations from the
Royal Australian College of General
Practitioners and Diabetes Australia
is that any diagnosis of diabetes
is based on plasma blood glucose
levels from a laboratory, and an oral
glucose tolerance test if required, and
in Ms CW’s case this will need to be
confirmed by her GP.
• Dietician and/or podiatry review if
necessary.15
Recommendations
to the GP
Step 1 – Healthy eating, physical
activity, weight control
• In light of the possible link between
risperidone and diabetes the
risperidone should be ceased.
Also, her behaviour, could be best
managed with diversional therapy.
• Whilst addressing the inappropriate
use of psychotropic medications,
clonazepam could be further
reduced in dose as she has been
seizure free for some time and
a previous halving in dose was
tolerated well.
• Consider reviewing Mrs CW in
light of her risk factors for diabetes
and her most recent fasting blood
glucose level of 10.2 mmol/L.
• If her fasting plasma glucose
confirms diabetes consider the
following:
– Pathology tests15
oo Hba1c
oo Lipids – see below for
dyslipidaemia targets and
management.
oo Albumin:creatinine ratio
(detects presence of
microalbuminuria)
780
• Consider the use of low dose
aspirin for cardiovascular event
prevention.15
Management targets and
options for type 2 diabetes
How to best achieve target
blood pressure management
in diabetes14
Step 2 – ACE inhibitor or ATII receptor
antagonist if ACE inhibitor not
tolerated
Step 3 – ACE inhibitor (or ATII receptor
antagonist as above) and thiazide
diuretic
Step 4 – Calcium channel blocker or
beta-blocker
Management of dyslipidaemia
in diabetes
Dyslipidaemia is common in patients
with diabetes and is an independent
risk factor for the macrovascular
complications of diabetes. It is
therefore important to identify and
treat dyslipidaemia. Generally, dietary
measures should be attempted for
3–6 months and if this is unsuccessful
then pharmacological treatment
can be implemented. The National
Heart Foundation targets for lipids in
patients with diabetes is as follows:16
• Total Cholesterol – <4.0 mmol/L
• Triglycerides – <1.5 mmol/L
• HDL – >1.0 mmol/L
• LDL – <2.5 mmol/L
Renal disease
Detection of proteinuria (protein in
the urine) is important to identify early
renal damage from diabetes. Initially,
low grade albuminuria (albumin in the
urine) can occur and at this stage can
often be managed with tight blood
pressure and glycaemic control.14
The albumin:creatinine ratio (ACR) is
useful for detecting and monitoring
microalbuminuria.
Outcomes of the
medication review
• Risperidone was ceased and the
clonazepam dose was reduced
initially to 0.5 mg in the morning
and 1 mg at night – planned dose
reductions of ~20% of the total
dose per month.
• The GP performed a fasting plasma
glucose test – 11.4 mmol/L and
a repeat test one week later –
11.7 mmol/L and a diagnosis of
type 2 diabetes was made.
• Hba1c performed – 8.3%
• Lipids
– HDL – 1.3 mmol/L
– LDL – 4.5 mmol/L
• ACR – 3.3 mg/mmol
(0-3.5 mg/mmol)
• Commencement of metformin
500 mg immediate release
once a day
• 3 months trial of diet and lifestyle
modification (GP unconvinced that
this will result in a discernable
change and a statin will most likely
be required)
• Blood pressure – average taken by
nursing staff and GP over a 2-week
period was 147/87 mmHg. Dose
increase of perindopril arginine to
10 mg daily.
• Influenza and pneumococcal
vaccination given.
• Referral for dietitian and
optometrist review.
• Commencement of aspirin
100 mg daily.
References
1. Westbury J, Tichelaar L, Peterson G, Gee P, Jackson S.
A 12-month follow-up study of ‘RedUSe’: a trial aimed
at reducing antipsychotic and benzodiazepine use in
nursing homes. Int Psychogeriatr 2011;1-10.
2. Westbury J, Beld K, Jackson S, Peterson G. Review of
psychotropic medication in Tasmanian residential aged
care facilities. Australas J Ageing 2010;29:72–6.
3. Westbury JL, Jackson S, Peterson GM. Psycholeptic
use in aged care homes in Tasmania, Australia. J Clin
Pharm Ther 2010;35:189–93.
medication review
The articles in this series are independently researched and compiled by PSA commissioned authors and peer reviewed.
Continuing Professional Development
4. Westbury J, Jackson S, Gee P, Peterson G. An effective
approach to decrease antipsychotic and benzodiazepine
use in nursing homes: the RedUSe project. Int
Psychogeriatr 2010;22:26–36.
5. Mansdorf IJ, Sharma R, Perez M, Lepore AM. Falls
reduction in long-term care facilities: a preliminary
report of a new internet-based behavioral technique.
Journal of the American Medical Directors Association
2009;10:630–3.
6. Wilson KC, Mottram PG, Vassilas CA.
Psychotherapeutic treatments for older depressed
people. Cochrane database of systematic reviews
2008:CD004853.
7. US FDA. FDA Public Health Advisory: Deaths with
antipsychotics in elderly patients with dementia; 2003.
8. Deberdt WG, Dysken MW, Rappaport SA, et al.
Comparison of olanzapine and risperidone in the
treatment of psychosis and associated behavioral
disturbances in patients with dementia. Am J Geriatr
Psychiatry 2005;13:722–30.
9. Lambert BL, Cunningham FE, Miller DR, Dalack GW,
Hur K. Diabetes risk associated with use of olanzapine,
quetiapine, and risperidone in veterans health
administration patients with schizophrenia. Am J
Epidemiol 2006;164:672–81.
10. Farwell WR, Stump TE, Wang J, Tafesse E, L’Italien
G, Tierney WM. Weight gain and new onset diabetes
associated with olanzapine and risperidone. J Gen
Intern Med 2004;19:1200–5.
11. Moisan J, Gregoire JP, Gaudet M, Cooper D. Exploring
the risk of diabetes mellitus and dyslipidemia
among ambulatory users of atypical antipsychotics:
a population-based comparison of risperidone and
olanzapine. Pharmacoepidemiol Drug Saf 2005;14:
427–36.
12. Dunstan DW, Zimmet PZ, Welborn TA, et al. The rising
prevalence of diabetes and impaired glucose tolerance:
the Australian Diabetes, Obesity and Lifestyle Study.
Diabetes Care 2002;25:829–34.
Questions 13. Colagiuri S, Davies D, Girgis S, Colagiuri R. National
Evidence Based Guideline For Case Detection and
Diagnosis of Type 2 Diabetes. Canberra; 2009.
14. Diabetes Australia. Diabetes Management in General
Practice 2009/2010; 2009.
15. Chadban S, Howell M, Twigg S, et al. National
Evidence Based Guideline for Diagnosis, Prevention
and Management of Chronic Kidney Disease in Type 2
Diabetes. Canberra; 2009.
16. Tonkin A, Barter P, Best J, et al. National Heart
Foundation of Australia and the Cardiac Society of
Australia and New Zealand: position statement on lipid
management – 2005. Heart Lung Circ 2005;14:275–91.
A score of 3 out of 4 attracts 0.75 CPD credits.
1. Which of the following is
LEAST likely to be an adverse
effect of risperidone?
a) Weight gain.
b)Falls.
c) Unsteady gait.
d) Leg cramps.
2. Approximately how many
Australians are estimated to
have UNDIAGNOSED type 2
diabetes?
a)250,000.
b)500,000.
c)750,000.
d)1,000,000.
c) Perform a capillary BSL test for
confirmation.
d) Repeat the test in 12 months.
3. What would be the MOST
appropriate assessment for
a person with a laboratory
performed fasting BSL of
9.3 mmol/L?
a) Diagnosis of diabetes.
b) Perform an oral glucose
tolerance test.
4. Which of the following is NOT
generally recognised as a
symptom of type 2 diabetes?
a)Hunger.
b)Thirst.
c) Weight loss.
d) Blurred vision.
e)Headaches.
September 2011
Note: The CPD questions are now at
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Vol. 30 – September #09, 2011
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