Appendix C

Multidisciplinary Care in Action

People with diabetes may present with a complaint best treated with multidisciplinary care. Common symptoms or concerns and possible presentation and management scenarios are given below as examples.

Foot and Skin Care

• Dry skin.
• Wounds, fungal and bacterial infections, ulcers.
• Pain, numbness, tingling of extremities.
• Corns, calluses, bunions, ingrown toenails.

Example:

A person requests a foot soak from the pharmacist for an ingrown toenail. Assessment reveals that he or she has diabetes and for 3 weeks has had a severely inflamed ingrown toenail that has not responded to topical antibiotic ointment. The pharmacist discusses with the person the relationship between diabetes and its complications, as well as the need to seek immediate attention from a podiatrist or primary care physician. The pharmacist also emphasizes that people with diabetes should NOT soak their feet. Soaking dries the skin and can cause more skin and foot complications.

Eye Health

• Dry itchy eyes.
• Blurred vision, poor vision (seeking reading glasses).
• Eye pain.
• Conjunctivitis.
• Other eye problems such as partial vision, hemorrhages, floaters, “spots,” foreign objects, contact lens problems.

Example:

A 45-year-old woman tells her podiatrist that she can’t check her feet because she “just can’t see as well” as she used to. She was recently diagnosed with diabetes. She assumed that she needed reading glasses, but has not had an eye exam because she never had poor vision before. The podiatrist recognizes that the patient’s blurred vision could be a sign of poor glucose control or eye pathology, and explains to her the relationship between diabetes and vision problems, both transient and long term. The podiatrist then refers the patient to an optometrist or an ophthalmologist for a comprehensive eye examination, including pupil dilation, and to a primary care provider for follow-up.

Oral Health

• Sore, red, inflamed, bleeding gums.
• Toothache, pain, infections.
• Dry mouth.
• Candida infections.
• Denture pain.
• Cold sores, canker sores.

Example:

A person with diabetes asks the pharmacist for a product to use as a mouth rinse for irritated gums. Assessment reveals that the person has poorly controlled diabetes and symptoms consistent with oral candida infection.
The pharmacist briefly explains the relationship between diabetes and oral health, and refers the patient to a dentist for treatment. Follow-up care for diabetes with a primary care provider is also arranged.

Medication Management

• Multiple medications.
• Varying instructions on how to take medications.
• Drug-drug interactions.
• Over-the-counter treatments, herbals, home remedies.
• Symptoms attributed to medication side effects.

Example:

A dental hygienist asks if a patient’s medications have changed since the last visit and discovers the patient is confused about how to take a newly prescribed medicine. The patient asks if “twice a day” means with breakfast and dinner, morning and bedtime, or at precise times such as 8 a.m. and 8 p.m. He further asks if the medication may be taken at the same time as other medications, because he takes several other medications for blood pressure and cholesterol as well as glucose control. He states: “It’s hard to find time to take all these medicines in one day!” The dental hygienist reinforces the importance of taking the medicine as directed, and suggests consulting with the provider who prescribed the medicines and with the pharmacist to ask these questions. The pharmacist may be more immediately accessible, can provide counseling on potential drug interactions, and can work with patients who are on complicated medicine regimens to work out an individualized schedule.

May 2007

National Diabetes Education Program (NDEP)    http://ndep.nih.gov
NIDDK, National Institutes of Health, Bethesda, MD

A Joint Initiative of the National Institutes of Health and the
Centers for Disease Control and Prevention