Page 66 - Retail Pharmacy November/Decemeber 2020

HEALTH HYPERGLYCAEMIA 65 “fairly high” for this to happen. “The renal threshold is around 12mmol/lt and then you’re losing glucose in your urine, so that’s where you’re going to start losing weight,” he said. “But that’s relatively high blood glucose levels. Hopefully, it will have been picked up \[before that stage\] ... at least in Australia.” Hyperglycaemia management The management of hyperglycaemia is multifactorial, often including a combination of medication, diet and exercise, which Dr Barclay refers to as “the three pillars”. Ms Crow said: “For people with type 1 diabetes, they should contact their doctor or credentialled diabetes educator for advice on increasing their dose of short acting insulin at mealtimes. “Extra doses of short acting insulin may also be required to treat the hyperglycaemia and bring down the blood glucose levels. They should also check their blood ketones and follow their sick-day management plan and seek medical treatment if their blood glucose and ketones continue to rise.” For those with type 2 diabetes, Ms Crow says, “ongoing hyperglycaemia can mean that their medication is no longer effective ... and they need to see their doctor”. From a more complementary approach, Mr Quigley suggests a number of other products that can “make a difference”, including olive leaf extract, which “helps our pancreas produce sufficient insulin”, fenugreek, cinnamon, and bitter melon – which he says has been the focus of much research. “A common one in Ayurvedic medicine is called Gymnema,” he said. “It works for all blood glucose issues ... So, they’re the herbal options. Even garlic has a role to play.” From a lifestyle perspective, Ms Crow adds that “sometimes people may have had a change in diet or lifestyle that may cause their blood glucose to be higher”, with Christmas often an occasion during which this happens. “Referral to a dietitian or exercise physiologist for dietary and physical assessment may help to reduce hyperglycaemia episodes,” she said. Dr Barclay said: “First and foremost, there’s very good evidence that by losing 7.5 per cent of your body weight ... you can go back to normoglycaemia within a relatively short period of time ... six to 12 months. So, losing weight should be the first focus. And part of that, of course, is increased physical activity.” He cites the importance of a dietitian in “going through what people are eating and finding those sources of unnecessary calories that might be high in energy but low in other essential nutrients \[such as\] vitamins, minerals and dietary fibre, and other important dietary factors ... what we call discretionary foods – junk foods”. “People with diabetes, like anybody else, need to eat a good balanced diet,” Dr Barclay said. “They need to be mindful of the carbohydrates \[choosing the right type and amount\] ... excessive protein can be converted into glucose, and excessive fat can contribute to insulin resistance – it’s got to be balanced: not too high in fat or protein, not too low in carbohydrates or you’ll miss out on the dietary fibre and the vitamins and minerals that ... are in higher carbohydrate foods. “Cutting out discretionary foods as much as people can \[is important\]. People don’t need to have a treat every single day. “If they’re drinking regular soft drinks or other sugar-sweetened drinks, switching to water or a diet soft drink is a better option.” Pointing to “interesting research” from the UK, the DIRECT clinical study, Dr Barclay says one of the findings in terms of weight-loss recommendations is that “with weight loss, the pancreas, which increases in size \[with diabetes\], goes back to normal”. “They’re really pushing that in the UK,” he said. “I think eventually we’ll catch up with the UK and start recommending that for people with type 2 diabetes \[a 15 per cent loss of body weight should be the goal\] ... it’s really quite exciting. It just shows that the body will recover given the right chance.” Ultimately, though, when it comes to dietary advice and the pharmacist’s role, Dr Barclay reinforces that “everybody with diabetes should be seeing a dietitian ... and to encourage that as part of the healthcare team is really important”. “There’s very good evidence that by losing 7.5 per cent of your body weight ... you can go back to normoglycaemia. So, losing weight should be the first focus.” Ms Crow says a person may experience the following conditions if hyperglycaemia is left untreated: Diabetes ketoacidosis (DKA) Most commonly, untreated hyperglycaemia causes DKA in people with type 1 diabetes, Ms Crow says. “This occurs when the blood has high and persistent blood glucose levels for six or more hours (>15mmol/ lt) and high ketone levels (>0.6mmol/ lt),” she said. “A build-up of ketones in the blood makes the blood too acidic and leads to a loss of fluids and body salts. This becomes a hyperglycaemic emergency.” She cites the following signs of DKA: • Nausea, vomiting and/or stomach pain. • Rapid breathing or breathlessness. • Drowsiness, confusion or weakness. • Increased thirst or dry mouth. • Reduced or no urine output. • Breath that smells ‘fruity’. Euglycaemic ketoacidosis (EK) “This is a rare condition that can occur in people with type 1 or type 2 diabetes and are pregnant, patients on a low carbohydrate diet or using sodium-glucose co-transporter 2 inhibitors (SGLT2i) or had recent surgery,” Ms Crow said. “EK occurs when high blood ketones and acidosis occurs in the presence of normal (or minor elevations) of blood glucose levels.” Hyperosmolar hyperglycaemic state (HHS) “HHS is more common in people with type 2 diabetes who experience acute sepsis, a myocardial infarction, stroke or kidney dysfunction,” Ms Crow said. “It’s more likely to occur in the elderly. HHS occurs when a person experiences ongoing and persistent high blood glucose, without ketones in the blood, and is severely dehydrated. People may experience an altered state of consciousness, a dry mouth, thirst and reduced urination. HHS can lead to a coma.” Ms Crow added: “People should seek urgent medical attention if they’re suspected to have any of these symptoms/conditions.” RETAIL PHARMACY • NOV/DEC 2020