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LEARNING OBJECTIVES

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  1. Identify appropriate standards for the diagnosis of diabetes and determine risk and prognosis for developing complications of poorly controlled diabetes mellitus.

  2. Use available parameters to measure and monitor target blood glucose and A1C goals for patients under treatment for diabetes mellitus.

  3. Conduct a comprehensive follow-up visit for a patient with diabetes mellitus using appropriate history-taking techniques, physical examination, and laboratory tests. The visit includes assessment of disease control, plus assessment and support of compliance with lifestyle modifications and medication regimens.

  4. Evaluate patients for complications from diabetes mellitus and the medication regimen.

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INTRODUCTION

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More than 25 million Americans have diabetes mellitus, 90% to 95% of whom have Type 2 diabetes mellitus. The economic burden of diabetes is almost $250 billion annually. Because most patients with Type 2 diabetes have the metabolic syndrome, with concomitant hypertension and hyperlipidemia, the average number of medications per patient ranges from 4.1 to 5.9. Because of the reliance on medication to control diabetes and its comorbid conditions, the pharmacist is a key member of the health care team in the management of patients with diabetes. Not surprisingly, there are numerous studies demonstrating the pharmacist’s effectiveness in managing Type 2 diabetes. Therefore, this chapter focuses on the competencies required by pharmacists to assume a primary care role in the treatment of patients with Type 2 diabetes mellitus.

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CLASSIFICATION/ETIOLOGY

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There are two main forms of diabetes mellitus (Table 20.1). The first is Type 1 diabetes, also previously known as insulin-dependent diabetes mellitus (IDDM) or juvenile onset diabetes. Type 1 diabetes is an autoimmune disease that results in the destruction of the β cells in the islets of Langerhans in the pancreas. Once 80% to 90% of the β cells are destroyed, severe glucose intolerance develops because of the lack of insulin. With little or no insulin available, patients are unable to use glucose. In response, the body breaks down proteins and fats for energy, frequently resulting in the development of ketoacidosis, which can be fatal. Patients with Type 1 diabetes require insulin injections due to the lack of insulin production to control glucose and prevent ketoacidosis. The exact mechanism for this autoimmune process is unknown, but patients who develop Type 1 diabetes have a genetic predisposition and the β-cell destruction is triggered by either infectious, chemical, or dietary agents. Generally, patients who develop Type 1 diabetes mellitus do so as children or adolescents. In contrast to patients with Type 2 diabetes, who are overweight, patients with Type 1 are usually of normal body shape and weight. In some cases, the destruction is rapid, and the onset is sudden. In others the destruction is slower and may take up to a year to fully develop signs and symptoms.

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TABLE 20.1

Classification of Diabetes Mellitus

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