How to involve people with diabetes and CKD in their own care – what information must they have to manage their own condition effectively?

SECTION G

These slides were sponsored by Janssen and developed in conjunction with the BRS CKD Strategy Group, following an advisory board that was organised by Janssen. Bedrock Healthcare Communications provided editorial support to members of the advisory board in developing the slides. Janssen reviewed the content for technical accuracy. The content is intended for a UK healthcare professional audience only.

JOB CODE PHGB/VOK/0914/0018f Date of preparation: January 2015

Objectives and background for this learning resource

Introduction:

This learning resource has been developed as part of a medical education initiative supported by Janssen. The content of this slide kit has been developed by an advisory board of renal physicians, GPs and specialist nurses. The panel of experts includes members of the British Renal Society Chronic Kidney Disease (CKD) Strategy Group. Bedrock Healthcare, a medical communications agency, has provided editorial support in developing the content; Janssen has reviewed the content for technical accuracy.

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Educational objectives:

To provide clear and applicable clinical guidance on chronic kidney disease (CKD) in people with type 2 diabetes to primary care healthcare professionals To advise primary healthcare professionals on what people with diabetes need to know about their own condition with relation to CKD • • •

Usability objectives:

To provide essential, relevant and up to date information in concise presentations To enable primary healthcare professionals to locate, select and use the content of the learning resource, as appropriate to their needs To enable secondary care experts in CKD to refer their primary care colleagues to the resource 1

Contents overview This learning resource comprises the following 10 sections (A-E):

Section A

Introduction and overview of chronic kidney disease (CKD) in people with diabetes

Section B Section C Section D

Long-term impact of diabetes and the importance of optimal management of the condition Pathophysiology of diabetic nephropathy & risk factors for the development of CKD Appropriate monitoring for complications of diabetes in primary care – CKD as one of these complications

Section E

Prevention of diabetic kidney disease 2

Contents overview (cont.) This learning resource comprises the following 10 sections (F-J):

Section F

Optimal management of diabetic kidney disease: hypertension and glycaemia

Section G

How to involve people with diabetes and CKD in their own care – what information must they have to manage their own condition effectively?

Section H

What does the future hold for a person with well-managed diabetes and CKD?

Section I

What do the guidelines say and what do they mean in terms of the day-to-day management of CKD in people with diabetes?

Section J

Sources of further information and reading list 3

Section G – 3 key learning objectives

• • • Patient involvement is central to successful management of diabetes Patient self-management can make a difference in the outcomes related to diabetes Patients should be well informed about kidney disease and have mutually agreed management goals 4

The benefits of encouraging patient self-management and involvement

• The benefits of effective self-management of long term conditions can include: 1 – – – Empowering the patient Promoting a person’s dignity, self-determination and wellbeing Potentially achieving operational savings within healthcare systems • Self-management support forms a central aspect of chronic illness management 1 • – – A literature review involving at least 5,500 individuals residing in Europe (the majority in the UK) indicated a shift towards patient-centred self-care of diabetes and identified the following needs 1 Development of accessible and relevant education material Improved communication of disease-specific information between healthcare professionals and patients – – Improved communication between healthcare professionals and community resources Strategies to improve the convenience and cost of monitoring devices – A multidisciplinary approach by healthcare professionals

Reference:

1. Kousoulis AA et al. BMC Health Services Research 2014;14:453.

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A comprehensive care plan for people with diabetes and CKD

• • • • • • • • • • • Add patient details to chronic kidney disease (CKD) register with classification according to NICE guidance 1 Inform people they have CKD and explain what that means Involve people in their care and provide opportunities for self-management Measure and record proteinuria Manage blood pressure (BP) Manage blood glucose levels Provide diet & lifestyle advice Provision of annual eye checks Provision of annual foot checks Measure cardiovascular risk Identify progressive kidney disease and refer if appropriate

Reference:

1. NICE clinical guideline 182. Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care. July 2014.

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Providing effective patient education

• • Patient education is central to successful management of their condition Materials and tools such as this chart, explaining blood pressure readings 1 , can aid discussions with patients and support them in understanding their condition and the medication they are taking © Blood Pressure Association 2008

Reference:

1. Blood Pressure UK. The Blood Pressure Chart. Available at: http://www.bloodpressureuk.org/BloodPressureandyou/Thebasics/Bloodpressurechart. Website last accessed on 15.12.14.

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Patient self-management

• • • • • • • BP control: explain that reducing raised BP is a key factor in preventing the progression of CKD 1 BP monitoring: advise patients to monitor their own BP at home using equipment recommended by the British Hypertension Society Encourage patients to stop smoking if they currently do so Lifestyle modification: explain the importance of taking exercise and keeping to an ideal weight Blood sugar control: explain that good glycaemic control reduces the risk of development and progression of CKD 2 Diet: avoid processed, high-salt and high-fat foods Medicines management: – Give advice regarding over-the-counter medicines to avoid, due to impact on kidney function (particularly non-steroidal anti-inflammatory drugs [NSAIDs]) 3 – Patients should be advised to tell their pharmacist that they have CKD

References:

1. Botdorf J, Chaudhary K, Whaley-Connell A. Hypertension in cardiovascular and kidney disease.Cardiorenal Med. 2011;1:183–192. 2.National Kidney Foundation KDOQI Clinical Practice Guidelines for Diabetes and CKD: 2012 Update. Available at http://www.kidney.org/sites/default/files/docs/diabetes-ckd-update-2012.pdf

Website last accessed on 12.11.14. 3.NICE clinical guideline 182. Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care. July 2014. 8

Patient involvement in glycaemic control

• • Self-monitoring: – – Give advice about frequency and treatment goals Ensure your patient understands what the various definitions/numbers mean – e.g. discussion about HbA1c targets, blood pressure values and what eGFR means Diet and exercise: – – Ensure your patient understands the benefits of diet/exercise on blood glucose • • Give advice and support e.g.

Age appropriate advice regarding exercise Seek specialist dietetic advice regarding weight loss 9

Medicines management

• • • • • Patients should be made aware of the effects of over-the-counter medicines (especially NSAIDS) 1 and complementary therapies that could have an impact on their kidney function.

2 Always check the medicine is safe for people with kidney disease Remind patients to inform the pharmacist that they have kidney problems Consider temporarily stopping ACE inhibitors and ARBs in adults, children and young people with diarrhoea, vomiting or sepsis, until their clinical condition has improved and stabilised 3 Advise that some blood pressure tablets can be kidney protective (ACE inhibitors and ARBs) 4 and tell the patient if this applies to the medication they have been prescribed Remind patients to inform medical staff about their CKD and any recent changes made to their medication when admitted to hospital or attending a clinic

References:

1.NICE clinical guideline 182. Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care. July 2014. 2.Garbardi S et al. A Review of Dietary Supplement–Induced Renal Dysfunction. Clin J Am Soc Nephrol 2007;2: 757–765. 3.NICE clinical guideline 169. Prevention, detection and management of acute kidney injury up to the point of renal replacement therapy. August 2013. 4.Mangrum AJ, Bak ris GL. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in chronic renal disease: safety issues.Semin Nephrol. 2004;24(2):168-75.

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Enabling shared decision making Tactics to encourage and support with shared decision making:

• Avoid telling the patient what to do; listen to the patient – partnership is crucial • Allow the patient time to understand what you are telling them. Discuss their fears/worries and manage their expectations • Explain the treatment regimen fully • Not all patients will have the confidence or ability to collaborate in shared decision making – e.g. vulnerable people, such as the elderly – may require a management plan in place that ensures consistent and optimal care, utilising the support of family/carers 11

Section G – summary

• • • • Follow a comprehensive care plan for diabetes with CKD Inform patients that they have the power to prevent progression of their diabetic kidney disease Encourage and support self-monitoring and self-management Informed and shared decision-making should be encouraged 12