City Wide Update Event

Programme Overview 7.00 pm 'Legs Matter’ - Brenda King 7.30 pm Pre-conception Care for Women with Diabetes – Dr Soon H Song, Sallianne Kavanagh & Dr Jenny Stephenson  8.30 pm OTC Consultation Skills: Low Back Pain Workshop 9pm Close Kindly sponsored by GSK

Pre-pregnancy care in diabetes: Setting the scene Soon H Song MD FRCP Consultant Diabetologist Diabetes Lead for Antenatal Service Northern General Hospital Sheffield

Pre-pregnancy care in diabetes Good pre-pregnancy care leads to better antenatal outcomes Pre-conception treatment aims: folic acid 5mg daily (not low dose 400ug) stop teratogenic medications (statin, fibrate, ACE-I, ARB) HbA1c <48 mmol/mol Demographics are changing: Significant rise in women with type 2 diabetes of child bearing age 60% antenatal diabetes patients have type 2 diabetes Driven by increasing obesity in the young and gestational diabetes Majority of young type 2 diabetes patients under primary care

Pre-pregnancy care National Diabetes in Pregnancy Audit 2016 Sheffield data: 50% women not folic acid at booking Up to 10% were on teratogenic medications (ACE-I/ARB and statins) 70% have HbA1c > 48 mmol/mol Type 2 diabetes patients less likely to receive folic acid and more likely to receive teratogenic medications

Prescription of ACE-I/ARB and statins in diabetic women aged 15-45 yr Type 1 diabetes Type 2 diabetes n=431 n=784 ACE-I 2.3% 13.9% ARB 2.5% 3.9% Statin 22.0% 33.2% Data from Sheffield CCG June 2018

Pre-pregnancy care: Opportunities for improvement: Raise awareness of good pre-pregnancy care as part of routine diabetes care for all diabetic women of child-bearing age (50% pregnancies are unplanned) Prioritise personalised approach to women who had stillbirth, miscarriage, congenital abnormality Refer to antenatal diabetes team for pre-pregnancy counselling and care especially type 2 diabetes – insulin start, changes to diabetes treatment Innovative approach to improve uptake of pre-pregnancy care in community - role of community pharmacists

Involving pharmacists in the community with pre-pregnancy care GP practice-based and community pharmacists Raise awareness on importance of planning for pregnancy Give advice on basic pre-pregnancy care Medication review - start folic acid 5mg and/or stop teratogenic medications Expand clinical role of pharmacists in the community Collaborative working with GPs and practice nurses to improve care Selected for National Diabetes in Pregnancy Quality Improvement Collaborative

How can pharmacy teams support women with diabetes? Sallianne Kavanagh Lead pharmacist- Diabetes and Endocrinology Sheffield Teaching Hospitals NHSFT sallianne.kavanagh@sth.nhs.uk

Context More women are going into pregnancy with increased body weight Increased risk of GDM, undiagnosed DM2 Maternal glucose crosses the placenta But insulin doesn’t Foetal hyperglycaemia Foetal rise in insulin secretion Pregnancy is a state of insulin resistance Especially towards the end Diabetes in pregnancy 90% GDM 10% pre-existing diabetes Note prevalence of both is increasing Hyperglycaemia in 1st trimester Risk of Major congenital abnormality DM1 5.9% DM2 4.4% GDM 1.4% Ref Farrel (2002) Diabetic medicine 19;4:322-326

Maternal complications of hyperglycaemia Pre- eclampsia UTIs Polyhydramnios, PROM Anomalies, spontaneous abortion Sudden IUD Increased use of instruments to assist delivery Birth trauma Operative delivery (C-section) Increased risk if GDM if subsequent pregnancies Increased risk of developing Type2 diabetes

Complications for the child Foetal complications Later in life 4x risk of congenital anomalies (pre-existing DM women) Macrosomia Shoulder dystocia Prematurity Respiratory distress syndrome Hypoglycaemia Jaundice Obesity DM Reproductive problems Metabolic syndrome HAPO study 2008 ‘ strong continuous associations of perinatal outcomes’ Carry graver consequences Preconception planning is important# good glucose control imp to prevent complications during organogenesis (1st trimester)

Clinical guidelines The National Institute for Health and Clinical Excellence (NICE) guideline for diabetes in pregnancy- NG3 (August 2015) https://www.nice.org.uk/guidance/ng3 Covers the care and treatment of pregnant women with diabetes in the NHS in England and Wales, and the care of their newborn babies It is written for women who have diabetes or who develop gestational diabetes in pregnancy Some of the recommendations include preconception advice for adolescents screening for women at risk of gestational diabetes the induction of labour or caesarean section after the 38th week of pregnancy Aim to empower women with diabetes to have a positive experience of pregnancy and childbirth by providing information, advice and support that will help to reduce the risks of adverse pregnancy outcomes for mother and baby

Clinical guidelines: Preconception Planning to become pregnant Establishing good blood glucose control before conception and continuing this throughout pregnancy will reduce the risk of miscarriage congenital malformation stillbirth neonatal death It is important to explain that risks can be reduced but not eliminated Level of risk is associated with how long she has had diabetes

Clinical guidelines: Preconception Provide information about how diabetes affects pregnancy and how pregnancy affects diabetes The role of diet, body weight and exercise The risks of hypoglycaemia and impaired awareness of hypoglycaemia during pregnancy How nausea and vomiting in pregnancy can affect blood glucose control Hypoglycaemia due to poor intake Hyperglycaemia due to stress response The increased risk of having a baby who is large for gestational age increases the likelihood of birth trauma, induction of labour and caesarean section The need for assessment of diabetic retinopathy before and during pregnancy The need for assessment of diabetic nephropathy before pregnancy The importance of maternal blood glucose control during labour and birth and early feeding of the baby, in order to reduce the risk of neonatal hypoglycaemia The possibility of temporary health problems in the baby during the neonatal period, which may require admission to the neonatal unit The risk of the baby developing obesity and/or diabetes in later life

Clinical guidelines: Preconception & medication Start Folic acid 5mg- note higher dose compared to the general population Advise women with diabetes who are planning to become pregnant to aim to keep their HbA1c level below 48 mmol/mol (6.5%) if this is achievable without causing problematic hypoglycaemia Women with diabetes may be advised to use metformin as an adjunct or alternative to insulin in the preconception period and during pregnancy Likely benefits from improved blood glucose control outweigh the potential for harm All other oral blood glucose‑lowering agents should be discontinued before pregnancy  insulin ACEi and ARBS should be discontinued before conception Alternative antihypertensive agents suitable for use during pregnancy should be substituted Statins should be discontinued before conception

Clinical guidelines: Target blood glucose levels Fasting: 5.3 mmol/litre 1 hour after meals: 7.8 mmol/litre or 2 hours after meals: 6.4 mmol/litre Advise pregnant women with diabetes who are on insulin or glibenclamide to maintain their capillary plasma glucose level above 4 mmol/litre avoid hypoglycamia

Role of the pharmacist Identify patients Change in request for contraception MECC conversations NMS/MUR Targeted medicines review for CCG medicines management pharmacist and GP pharmacist Systems review- HbA1c good/low on at risk drugs Repeat purchase of glucose tablets Patient education- hypoglycaemia awareness Polypharmacy review Adherence reviews Healthy living pharmacy campaign

Role of the pharmacist- NMS/MUR Medication discussions for women with diabetes who may wish to become pregnant Adherence Essential to achieving the ideal pre-pregnancy HbA1c Folic acid Refer to GP practice service for Folic acid 5mg Polypharmacy review Refer to GP practice service for CI medication to be reviewed Statins ACE/ARB Oral diabetes medications (except metformin)

Information prescriptions Available from Diabetes UK website: Information to be provided for women. Local version created The risk Medication Blood glucose Folic acid Lifestyle Co-design crib sheets for NMS/MUR

Interested and want to know more? Women with diabetes: University eLearning package- free to access http://www.qub.ac.uk/elearning/public/WomenWithDiabetes/Introduction/ Preconception care for diabetes: The Health foundation http://patientsafety.health.org.uk/resources/proceed-preconception-care- diabetes Planning a pregnancy when you have diabetes- DUK video https://www.diabetes.org.uk/Guide-to-diabetes/Life-with- diabetes/Pregnancy NHS choice- your pregnancy and baby guide https://www.nhs.uk/conditions/pregnancy-and-baby/diabetes-pregnant/

PLANNING PREGNANCY- WHAT HAPPENS IN PRACTICE? Dr Jenny Stephenson, GP. 11.June 2018

COMMUNITY - THINK ‘AT RISK’! Community Pharmacists and GPs/PNs need to be aware - 1. The diabetic woman consulting you may get pregnant, anytime 2. Mother & baby outcomes are so much better if she can be prepared BEFORE becoming pregnant 3. Certain common drugs can cause harm to the baby 4. Poor diabetic control around conception time can cause harm to mother and baby ACTION: consider having a computer flag on notes of women with diabetes aged 15-50? Sheffield Diab Template has a relevant page

GP - WHAT HAPPENS IN PRACTICE? GPs and PNs use the Sheffield Diabetes Template to record data and checks. It has a checklist regarding pre-pregnancy advice During routine Diabetes checks, pregnancy risk will have been discussed, and if deemed at risk of pregnancy then she must be warned about optimising control of HBA1c/glucose If not at risk, eg sterilisation, then consider flagging the notes accordingly, to prevent asking again GPs do Medication Reviews every 6-12 months depending on recall. They need to be alert to dangers of statins, ACE inhibitors, and some oral hypoglycemic drugs other than metformin

COMMUNITY - RAPID RESPONSE! Patients self refer via the Receptionists to the Specialist Team Receptionists need to know the protocol Community Pharmacists will come across this potential problem – to increase awareness for during MURs or general contact May be difficult for a Pharmacist to broach the subject, but perhaps needs to think to ask, confidentially, if there is a pregnancy risk if a woman of this ‘age group’ is on any of the potentially teratogenic drugs

COMMUNITY– RAPID REFERRAL! At the desk, the Receptionists need to direct the pregnant diabetic woman to the Specialist Team - urgent fax referral on 0114 2268922 She also needs to make an urgent referral to the Community Midwife Currently the slip of paper they are given by the Receptionist asks for their name and contact details only; the receptionist may not necessarily know or think to ask if she is diabetic, so training is required COMMUNITY PHARMACIST – advise the woman to discuss her potential or actual pregnancy with her GP Practice as soon as possible

PHARMACISTS » GPs When a community Pharmacist discovers a diabetic woman considering pregnancy, refer to GP or Specialist Nurse When a community Pharmacist has concerns following a MUR, eg a woman considering pregnancy but on potentially teratogenic drugs, refer to or contact the GP depending on the wishes of the patient Make a note that the issue has been discussed. Offer relevant literature or website advice. DISCUSSION

Low Back Pain Back Pain Additional reading: https://cks.nice.org.uk/back-pain-low-without-radiculopathy <accessed 5/6/18> https://www.thelancet.com/series/low-back-pain <accessed 5/6/18> https://www.nice.org.uk/guidance/ng59 Low back pain and sciatica in over 16s: assessment and management <accessed 5/6/18>

Close Thank you all for attending Thank you to all of our guest speakers Thank you to our Sponsor - GSK