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CPD 28: TYPE 2 DIABETES Biography - Ronan Sheridan graduated from the Robert Gordon University, Aberdeen in 2009 with a Masters in Pharmacy with Distinction. He worked for three years as a pre-registration and clinical pharmacist at the Chelsea and Westminster Hospital NHS Foundation Trust, London before joining Market Point and Green Road Pharmacy, Mullingar, Co Westmeath as pharmacist/manager. Sheridan was recently awarded the 2012 Helix Health Young Pharmacist of the Year.

Module 1 June 2012

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- will this article satisfy those needs - or will more reading be required? learning needs - and how has my practise changed as a result? Have I identified further learning needs?

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Chronic Pain5. WHAT – assessment and management in primary care NEXT - At this time you may like

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Objectives

Type 2 Diabetes •

Describe chronic pain, its prevalence and consequences of inadequate management

I dentify barriers in primary care to effective diagnosis and assessment of chronic pain and develop strategies to overcome these barriers

iscuss both pharmacologic and non-pharmacologic therapeutic options and benefits of D 60 multidisciplinary care Second Classification and Prevalence - Diabetes mellitus refers to a group of metabolic •

disorders characterized by hyperglycemia associated with abnormalities in carbohydrate, Summary fat and protein metabolism and resulting in chronic complications including microvascular, 2 Sheehan et alType reported in 1996 that the estimated cost of Introduction macrovascular and neuropathic complications1. diabetes, or pain for 95 patients to the Irish Health Services when added non insulin In 1999, the World Health (WHO) updated the for classification the disease, Pain Organisation is one of the commonest reasons patients to of seek to the amountdependent of Social Welfare payments received and 1 recognising four typesmedical of diabetestype A 1 recent diabetes, typehas 2 diabetes, gestational survey shown that as many diabetes attention. diabetes, is patient amounted to 1.9 million the lost earnings of each and impaired fasting glycaemia. is estimated that worldwide 347 million people have characterised as 8.3 visitsItper year to primary care physicians in Ireland of referral.6 The recent data from PRIME diabetes, with this figure rising to the ageing population, poor survey diet and sedentarypounds at thebytime a relative 2 were duedue to symptoms of pain. A large scale carried deficiency of insulin survey show that the mean cost per chronic pain patient lifestyle. In 2004, an estimated 3.4 million people died from hyperglycaemic events. In out in 15 European countries and Israel in 2006, screening or a resistance to the Ireland approximately 190,000 people are living with diabetes, with this figure due to is almost estimated at €5,665 per year across all grades of pain, effects of insulin. 46,394 respondents reported that the prevalence of chronic which was extrapolated to €5.34 billion or 2.86% of Irish double by 20201. pain of moderate to severe intensity in adult Europeans was Type 2 diabetes accounts for 90-95% of all 7 GDP per year.cases, This compared demonstrates an urgent for cost to 5-10% which need accounts 19%.3 for type Until recently, this typeeffectively. of diabetes effective strategies to1.manage chronic pain was seen only in adults but it is now also Type 2 diabetes, or non More insulinrecent dependent However thestudy, clinical presentation can differ in survey data from another carried out occurring in children. diabetes, is characterised by a relative a variety of ways, as outlined below. Patients in 2,019 people with chronic pain and 1,472 primary Understanding chronic pain deficiency of insulin or a resistance to the will also present with elevated blood glucose An HbA1c of 48 mmol/mol (6.5%) is physicians 15 European countries, have insulin levels, as effects of insulin. It is notcare so much a lackacross of levels, as well as elevated as the cut point for diagnosing Chronic pain recommended is defined as pain that outlasts normal healing insulin that causes the symptoms, but athat failure compensates achieve glucose diabetes demonstrated chronic the painbody affects 12-54% ofto adult 1,2 time (usually three to six months), and is most frequently of target organs to respond normally. It has a homeostasis . its prevalence in Ireland is up to 13%.2 The Type 2 diabetes is commonly associated slow onset of symptomsEuropeans, and for thisand reason associated with musculoskeletal disorders such as low Signs and Symptoms of Type 2 Diabetes with elevated blood pressure, a disturbance (Prevalence, can remain undiagnosedPRIME for several years, Impact and Cost of Chronic Pain) study, back pain and arthritis. However, it can also be associated of blood lipid levels and increased risk of often until secondary complications • Candidiasis on the otherhave hand, determined the prevalence of chronic thrombosis development. Theor cardiovascular with other disorders such as depression metabolic arisen. Type 2 diabetes accounts for 90-95% of pain towhich be as accounts high as 35.5%• inBacterial Ireland.4urinary The PRIME study risk associated with type 2 diabetes means tract infections all cases, compared to 5-10% disorders or neurologic such as multiple the goals ofconditions therapy must: for type 1. Until recently,was this designed type of diabetes to investigate the prevalence of chronic pain • Genital itching sclerosis. was seen only in adults in butIreland; it is now also the psychological and physical health compare • achieve normoglycaemia and HBA1c occurring in children1. • Foot ulceration targets profiles of those with and without chronic pain; and explore Pain (acute or chronic) can be categorised as nociceptive RISK FACTORS FOR DEVELOPMENT • Erectile dysfunction 4 pain-related disability. Responses to survey questions were • Minimise occurrence of hypoglycaemic or neuropathic. Nociceptive pain is caused by an active events 90% of patients who develop typefrom 2 diabetes • Tingling, pain and numbness in obtained 1,204 people. illness, injury and/or inflammatory process associated with are clinically obese (i.e. a BMI of >25). Other peripheral limbs • Minimise risk factors/ long termpain actual or potential tissueother damage i.e. Nociceptive risk factors include decreased physical Despite the magnitude of the problem, chronic pain is complications • Cardiovascular complications exercise, unhealthy diets, hypertension, results from activity in neural pathways secondary to actual under-recognised and undertreated in primary care.2,5 ageing population (> 40 both yrs), dyslipidemia • Encourage self care through education • Persistent or recurrent infections or potential tissue damage. Nociceptive pain is mediated and smoking. A family member withtodiabetes Indeed, up 38% of patients reported being inadequately by pain receptors located in skin, musculoskeletal system, can also predispose one to developing the • Cataracts • Tailor pharmacological therapy to meet the managed in primary care for their pain symptoms.2 In 1 8 disease . needs of the patient bone, and joints. Neuropathic pain, on the other hand, • Development of microalbuminuria addition, people with chronic pain reported waiting up to SIGNS & SYMPTOMS results from direct injury tohave a peripheral or central sensory Pharmacists an important role to play 2.2 years between seeking DIAGNOSIS help and diagnosis, and 1.9 in preventing long termproduce complication with nerve; the affected nerves do not transduction at The characteristic symptoms of type 2 diabetes 2 disease progression. years before their pain was The adequately managed. criteria for a diagnosis of diabetes are, in 8 include polydipsia, polyuria and blurred vision.

nociceptors. Pain characteristics and associated conditions for both types of pain are shown in Table 1.

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CPD 28: TYPE 2 DIABETES patients with characteristic symptoms along with either • A random venous plasma concentration > 11.1 mmol/l

Module 1

Or

2012 • a fasting plasma glucoseJune concentration > 7.0 mmol/l Or

sionals • intwo Ireland hour plasma glucose concentration >

11.1 mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT).

anagement in primary care In 2011 WHO recommended that the HbA1c

can be used as a diagnostic test for diabetes providing that stringent quality assurance tests are in place. An HbA1c of 48 mmol/mol (6.5%) is recommended as the cut point for diagnosing diabetes. A value of less than 48 mmol/mol (6.5%) does not exclude diabetes ces of inadequate management diagnosed using glucose tests1,2,3.

and assessment of chronic pain and develop MANAGEMENT Type 2 diabetes is commonly associated

with elevated blood pressure, a disturbance therapeutic options and benefits of

of blood lipid levels and increased risk of thrombosis development. The cardiovascular risk associated with type 2 diabetes means the goals of therapy must:

HBA1c cost targets ehan et • al achieve reportednormoglycaemia in 1996 that theand estimated of • Minimise occurrence of hypoglycaemic n for 95 patients to the Irish Health Services when added events he amount of Social Welfare payments received and • Minimise riskamounted factors/ long lost earnings of eachother patient to term 1.9 million complications 6 nds at the time of referral. The recent data from PRIME Encourage selfcost careper through education vey show• that the mean chronic pain patient stimated• atTailor €5,665 per year across all grades of pain, pharmacological therapy to meet the 4 needs of the ch was extrapolated to patient €5.34 billion or 2.86% of Irish 7 National Institute of Clinical Excellence has The P per year. This demonstrates an urgent need for cost developed a framework for the management ctive strategies to manage chronic pain effectively. of type 2 diabetes, which encompasses advice for self care, treatment of the disease and preventing complications2.

derstanding chronic pain

NICE GUIDANCE ON THE MANAGEMENT

onic painOF is TYPE defined as pain that9 outlasts normal healing 2 DIABETES e (usuallyEach threepatient to six months), and is most frequently will have an individual target ociated with musculoskeletal as low HBA1c, which may bedisorders above thesuch general target of 6.5%. At However, the initial stage diagnoses, k pain and arthritis. it canofalso be associated lifestyle mortification is the initial management. h other disorders such depression or metabolic If this does notas achieve a satisfactory HBA1c sufficient time, drug therapy is initiated. orders orafter neurologic conditions such as multiple rosis. PHARMACOLOGICAL THERAPY

Metformin n (acute or chronic) can be categorised as nociceptive The Nociceptive first line drugpain therapy for glycaemic control europathic. is caused by an active in type 2 diabetes is metformin. The dose can ss, injurybe and/or inflammatory process associated with titrated up over several weeks to minimise ual or potential tissue damage i.e. Nociceptive pain risks of gastrointestinal side effects. Metformin particularly beneficial for overweight ults from isactivity in neural pathways secondary patients, to actual but is also as effective in non-overweight otential patients. tissue damage. Nociceptive pain is mediated pain receptors located in skin, musculoskeletal system, Metformin acts by decreasing intestinal 8 e, and joints. Neuropathic pain, the othermuscle hand, absorption of glucose andon increasing uptake increasingorthe action of ults from glucose direct injury to abyperipheral central sensory insulin at its peripheral receptor. It is excreted ve; the affected nerves do not produce transduction at by the kidneys, and for this reason should iceptors.8 Pain characteristics and associated conditions both types of pain are shown in Table 1.

be avoided where there is a degree of renal insufficiency. Administration of metformin to patients with kidney insufficiency can cause a fatal form of lactic acidosis. Sulphonylurea Drugs within class: Gliclazide, Glipizide, Tolbutamide, Glimperidine, Glibenclamide A sulphonylurea is a suitable alternate to metformin if the patient is underweight or cannot tolerate or is contra indicted to metformin. It is also suitable if a rapid therapeutic response is required. They act by stimulating beta-cell insulin secretion and hence lower plasma glucose levels. They are metabolised by the liver and should be avoided in hepatic insufficiency. Once daily dosing can be a treatment option, if adherence is a problem. As sulphonylureas release insulin, they can cause hypoglycaemia, and blood glucose monitoring is advisable. They also have the potential is cause weight gain, thus diet and exercise must be an essential component of the treatment regimen.

is high or they are contraindicated or not tolerated. It can used in addition to a sulphonylurea if metformin is not suitable. Unlike the sulphonylurea, the risk of weight gain is significantly lower. Thiazolidinedione Drugs within class: Rosiglitazone and Pioglitazone This group of drugs improve glucose and lipid metabolism by their agonistic effect at the nuclear PPARγ receptor, increasing transcription of certain insulin sensitive genes. They are useful for patients whose glycaemic control is inadequately controlled by other oral treatments. They can also be used in combination with a sulfonylurea if metformin is not appropriate. They are not suitable for patients with established heart failure, and the use of Rosiglitazone may be associated with an increased risk of ischemia. Liraglutide Drugs within class: Victoza

Drugs within class: Sitagliptin, Saxagliptin and Vildagliptin

Liraglutide 1.2mg daily, only in dual therapy is recommended as a treatment option, in combination with metformin or a sulphonylurea, for type 2 diabetes if

The DDP-4 inhibitors are a suitable alternative to the sulfonylurea if the risk of hypoglycaemia

• The person is intolerant of either metformin or a sulphonylurea, or treatment

DPP-4 Inhibitors

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CPD 28: TYPE 2 DIABETES of diabetic complications, for example, eye and feet examinations or drug therapy management. Diabetic foot care As the majority of type 2 diabetics will seek Module 1 clarification before purchasing any2012 other the June counter foot care products, it is important to ensure the following general advice on foot care:

Educational distance learning content for healthcare professionals• inInspect Irelandfeet daily, including the tops, sides, heels, and between the toes

• When trimming toenails, cut them straight across, and round the edges slightly with an emery board

Chronic Pain – assessment and management in primary care •

Objectives

To prevent drying and cracking of the skin, use emulsifying ointment on the tops and bottoms of the feet but not between the toes, as this can cause a fungal infection

• Wear cotton, synthetic blend, or wool socks Describe chronic pain, its prevalence and consequences of inadequate management that are soft and dry to absorb moisture.

I dentify barriers in primary care to effective diagnosis and assessment of chronic pain and develop • To promote good circulation to the lower limbs when seated, prop your feet up and strategies to overcome these barriers

periods of time. iscuss both pharmacologic and non-pharmacologic therapeutic options and benefits of D • Immediately report any sores or skin multidisciplinary care

avoid standing in one position for long

changes, such as blisters, cuts, or soreness, to your diabetic team

not attempt to that remove or calluses Sheehan et • al Do reported in 1996 the corns estimated cost of without seeking the advice of your GP or 8 pain for 95 patients to team the Irish diabetic . Health Services when added Pain is one of the commonest reasons for patients to seek to the amount of Social Welfare payments received and 1 Smoking cessation medical attention. A recent survey has shown that as many the lost earnings of each patient amounted to 1.9 million with metformin or a sulphonylurea is Blood Pressure as 8.3 visits per year to primary care physicians in Ireland Not only is smoking 6 a risk factor for the contraindicated, and time of referral. The recent 2 development of diabetes, it candata also from be a PRIME People 2 diabetes should havepounds at the were due to symptoms of pain. A with largetype scale survey carried showcause that the meancomplications. cost per chronic pain patient of major Smoking a • The person is intolerant of thiazolidinediones their blood pressure taken at least once survey out in 15 European countries and Israelwhose in 2006, screening bloodallvessels, year. Those blood pressure is found and DDP-4 inhibitors, or treatment with a is estimatedaccelerates at €5,665 damage per year to across grades of pain, particularly the smaller blood vessels. This 46,394 respondents reported that the prevalence of chronic to be 140/80mmHg or higher should initially thiazoldidinediones and DDP-4 inhibitors is which was extrapolated to €5.34 billion or 2.86% of Irish can lead to poor circulation, which is a major offeredinadvice on lifestyle changes - such contraindicated. pain of moderate to severe be intensity adult Europeans was 7 risk factor for foot infections and, ultimately, as diet and exercise to help prevent further GDP per year. This demonstrates an urgent need for cost 3 Liraglutide 1.8mg is not 19%. recommended for the amputations. rises in blood pressure. The choice of agents effective strategies to manage chronic pain effectively. 5

Introduction

treatment of type 2 diabetes .

to reduce blood pressure, including ACE

co-morbidities.

with medication and other components of

Smoking doubles the chances of suffering from inhibitors, II receptor antagonists, More recent survey data from anotherangiotensin study, carried out Prolonged Release Exenatide kidney problems and erectile dysfunction. beta blockers, thiazide diuretics and longin 2,019 people with chronic pain and 1,472 primary Understanding chronic pain 6 acting calcium channel blockers . People with diabetes already have an increased Exenatide is licensed for the triple therapy care physicians across 15 European countries, have of heart as disease, which is further elevated regimens in combination with metformin Chronic painrisk is defined pain that outlasts normal healing Aspirin if they smoke. Diabetes acts in several ways and a sulphonylurea, or demonstrated metformin and that a chronic pain affects 12-54% of adult time (usuallytothree to six months), andglucose is mostlevels frequently 2 damage the heart; high affect Studies have shown taking thiazolidinedione, as a treatment option Europeans, andwhen its prevalence in Ireland is up tothat 13%. Thea low-dose with musculoskeletal disorders such more as low the walls of the arteries making them aspirin every day significantly lowers theassociated risk control of blood glucosePRIME remains high (HbA 1c ≥ (Prevalence, Impactofand Cost of Chronic Pain) study, likely to develop fatty deposits which in turn heart attacks. For diabetics there is aback 50% pain and 7.5), and the person has: arthritis. However, it can also be associated on the other hand, determined the prevalence ofdying chronic make it more difficult for the blood to circulate. increase in the risk of from heart disease, other disorders such as depression metabolic • a body mass index (BMI) kg/m2 andas 35.5% People with diabetes are moreorlikely to have therefore all4diabetics overstudy the age of 50with should pain≥to35be as high in Ireland. The PRIME specific psychological or medical problems blood pressure andsuch high as levels of fats disorders orhigh neurologic conditions multiple be offered low dose aspirin. was designed to investigate the prevalence of chronic pain such as triglycerides. They are also more likely associated with high body weight or PHARMACIST INhealth PREVENTINGsclerosis. to have lower levels of the protective HDL in Ireland; compare the psychological and ROLE physical • a BMI < 35 kg/m2, and therapy with COMPLICATIONS cholesterol. profiles of those with and without chronic pain; and explore Pain (acute or chronic) can be categorised as nociceptive insulin would have significant occupational • Support of self blood glucose monitoring 4 Eye Nociceptive checks disability. implications or weightpain-related loss would benefit Responses to survey questions were or neuropathic. pain is caused by an active other significant obesity-related • Monitoring and promoting patient adherence obtained from 1,204 people. mostinflammatory serious complication diabetes with illness, injuryThe and/or process of associated for the eye is the development of diabetic

actual or potential tissue damage i.e. Nociceptive pain self-management retinopathy. If the blood sugars are well Despite the magnitude of the problem, chronic pain is results from activity in neural secondary to actual controlled, then it pathways is less likely to be a problem. 2,5 Identifying and resolving drug-related issues bothshould under-recognised and• undertreated in primary care. People with type 2 diabetes expect complications lead to loss or potential More tissueserious damage. Nociceptivecan pain is mediated up to 38% reported targeted being inadequately • Providing education of vision, so diabetics should always be to have their blood lipid Indeed, levels checked on of patients by pain receptors located skin, musculoskeletal 2 encouraged to in regularly have their eyes system, tested. diagnosis and then at least once ainyear. managed primary care for• their pain symptoms. In Monitoring blood pressure, weight and bone, and joints.8 Neuropathic pain, on the other hand, Cholesterol levels should also be kept below cholesterol Diet Advice addition, people with chronic pain reported waiting up to 5mmol/litre. For those at increased risk of results from direct injury to a peripheral or central sensory 2.2 years between seeking help and diagnosis, and 1.9 cardiovascular risk, initiation of a statin may be • Reminding patients of the importancenerve; Diets fornerves type 2do diabetes should transduction be built the affected not produce at 2 appropriate even if levels are within . of regular managed. examinations for the presence around the principles of healthy eating with years beforerange their6pain was adequately 8 nociceptors. Pain characteristics and associated conditions for both types of pain are shown in Table 1. Cholesterol

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CPD 28: TYPE 2 DIABETES A healthy diet and weight range is key in Type 2 diabetes management

Module 1 June 2012

sionals in Ireland

anagement in primary care

ces of inadequate management

and assessment of chronic pain and develop

a focus on foods that do not adversely affect therapeutic options and benefits of

blood glucose levels. Patients should follow a 3 meal a day diet structure, including starchy carbohydrates at each one of the meals- bread, potatoes, rice and pasta. They should avoid or reduce the intake of foods rich in saturated and choose lowthat fat dairy products,cost of ehan et fats, al reported in 1996 the estimated substituting full fat milk or skimmed semin for 95 patients to the Irish Health Services or when added skimmed and low fat cheese and yogurts.

he amount of Social Welfare payments received and HEALTHY DIET OPTIONS FOR DIABETICS lost earnings of each patient amounted to 1.9 million • Eat levels6ofThe fat,recent particularly saturated nds at the timelower of referral. data from PRIME fat. vey show that the mean cost per chronic pain patient meat and fish stimated• atChoose €5,665chicken, per yearturkey, acrosslean all grades of pain, as low fat alternatives to fatty meats. ch was extrapolated to €5.34 billion or 2.86% of Irish • 7Eat five servings of fruit vegetables P per year. This demonstrates an and urgent need for cost every day- choosing from the rainbow of ctive strategies to manage pain effectively. colours availablechronic to maximize variety. • Avoid foods high in cholesterol, such as egg

yolks,chronic fatty meat,pain and fatty dairy products. derstanding

• Choose low-fat or completely fat-free dairy

onic pain isproducts, defined as that dairy outlasts normal healing or pain consider alternatives. e (usually three to six months), and is most frequently • Choose cholesterol-lowering fats, such as ociated with musculoskeletal disorders such ascontain low olive oil or canola oil. Many nuts also healthy k pain and arthritis.fats. However, it can also be associated h other disorders as depression metabolic • Eat oilysuch fish twice a week orormore, and focus on those fish that include levels of orders or neurologic conditions suchhigh as multiple heart-protective fat ( mackerel, trout, salmon rosis. and sardines).

• Cook using methods (baking, n (acute or chronic) canlow-fat be categorised as nociceptive roasting, grilling) and avoid frying. europathic. Nociceptive pain is caused by an active Focusinflammatory on foods thatprocess are high associated in fibre. ss, injury• and/or with • Eat less sodium andi.e. don’t add salt topain your ual or potential tissue damage Nociceptive food- in too muchpathways salt can increase the to risk of ults from activity neural secondary actual high blood pressure. otential tissue damage. Nociceptive pain is mediated • Drink alcohol in moderation - 2 units of pain receptors located in skin, musculoskeletal system, alcohol per day for a woman and 3 units per 8 e, and joints. day Neuropathic for a man. pain, on the other hand, ults from • direct a peripheral or central sensory Limitinjury sugartoand sugary foods e.g. desserts, ve; the affected nerves produce transduction cakes, sweetdo teanot and sugar-sweetened at 8 iceptors. drinks. Pain characteristics and associated conditions both types of pain are shown in Table 1.

REFERENCES 1. World Health Organisation 2012, Fact Sheet (312). Type 2 diabetes, viewed 4 February 2013, http://www.who.int/diabetes/action_ online/basics/en/index1.html 2. Wermeille J, Bennie M, Brown I. Integrating the community pharmacist into the diabetes team: Evaluation of a new care model for patients with type 2 diabetes mellitus. Int J Pharm Pract 2001;9:60 3. National Institute of Clinical Excellence. Guidance on the management of type 2 diabetes, 2009. 4. Venkatesan R et al. Role of community pharmacists in improving knowledge and glycemic control of type 2 diabetes. ISCR 2012; 3: 26-31 5. Novo nordish., Victoza 6mg/ml solution for injection. Summary of Product Characteristics 2012. 6. National Institute of Clinical Excellence. Management of type 2 diabetes - management of blood pressure and blood lipids, 2002. 7. O Donovan et al. The role of pharmacists in control and management of type 2 Diabetes Mellitus; a review of the literature. 2011 http:// journalofdiabetology.org/Pages/Releases/ PDFFiles/FOURTHISSUE/RA-1-JOD-10-023. pdf 8. National Institute of Clinical Excellence. Diabetes foot problems: Prevention and management of foot problems, 2004. 9. EPG, Professional channel for doctors. Type 2 diabetes, viewed 4 February 2013, http:// epgonline.org/images/diabetes/nice-carepathway.jpg

Pfizer Healthcare Ireland are committed to supporting the continuous professional development of pharmacists in Ireland. We are delighted to be partnering with Irish Pharmacy News in order to succeed with this. Throughout the year, Irish Pharmacy News will deliver 12 separate modules of continuous professional development, across a wide range of therapy areas. These topics are chosen to support the more common interactions with pharmacy patients, and to optimise the patient experience with retail pharmacy. We began the 2011 programme with a section on the Gastrointestinal System. Other topics include Diabetes (Types I and II), the Cardiovascular System, Smoking Cessation, Infections, Parkinson’s Disease, Alzheimer’s Disease, Depression and others. We hope you will find value in all topics. Pfizer’s support of this programme is the latest element in a range of activities designed to benefit retail pharmacy. Other initiatives include the Multilingual Pharmacy Tool, a tailored Medical Communications Programme, Educational Meetings and Grants, our Patient Information Pack, new pharmacy Consultation Room brochures and other patient-assist programmes including the Quit with Help programme and www. mysterypain.ie. If you would like additional information on any of these pharmacy programmes, please contact Pfizer Healthcare Ireland on 01-4676500 and ask for the Established Products Business Unit. EPBU/2013/033/1

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CONTINUING PROFESSIONAL DEVELOPMENT - 28 - 2013  

CPD 28: TYPE 2 DIABETES

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