New pharmacy approaches to diabetes management

When it comes to patients with diabetes, or any specific resident population for that matter, there are substantial benefits to having a strong relationship with a pharmacist. When pharmacists are knowledgeable about a specific population, it is more likely patients will feel understood. Further, that relationship with a pharmacist can provide a sense of accountability, which increases the likelihood that patients will remain engaged in their own wellness and self-care.

Pharmacists can help patients with diabetes make a connection between their elevated blood sugars and what may seem like ambiguous symptoms, such as fatigue, excessive thirst and frequent urination. Patients also need to be made aware of the long-term complications associated with diabetes, which can include heart disease, kidney disease, nerve damage, retinopathy and even limb amputation. All of these conditions can result from years of elevated blood sugar. And, for all of these conditions, adherence to prescribed treatments is critical not only for healthy living, but also in some cases for avoiding life-threatening situations.

Many patients also do not consider the effects of behavioral health on their ability to maintain treatment. I often tell patients that depression, when left untreated or undertreated, can become a vicious cycle for managing diabetes. Suboptimal treatment of depression can lead to emotional distress, which may interfere with their motivation for proper self-care. This lack of motivation commonly results in further uncontrolled blood sugar levels, which can ultimately lead to a worsening of the depression in addition to diabetes. The American Diabetes Association issued new guidelines to proactively address this by including mental illness as a comorbidity.  

To combat these challenges, our team at ProMedica Pharmacy Counter implemented an adherence program with a special multidose card that sorts patients’ medication by day and time. These cards essentially function as prefilled and pre-organized pill boxes. Pharmacists package and prepare the card that is delivered to patients with all their routine oral medications already organized. This alleviates patients’ burden and stress of having to properly sort through their prescriptions on their own—a process that carries substantial risk if improperly executed. The package, called the “SureMed Card,” is manufactured by Omnicell and is a solution for both individuals at home and those in assisted living facilities who are serviced within our ProMedica Health System.

Simplifying the process of organizing and taking medications is paramount to encouraging better adherence, but the first step is identifying which patients are nonadherent. We do this through an initial screening using our prescription processing system to identify which patients are not refilling their prescriptions on a timely and consistent basis. We also look for patients who present with polypharmacy and therefore could be candidates for deprescribing, or eliminating unnecessary medications. Family members and other healthcare providers are also frontline resources to help identify patients who may be at risk for medication nonadherence.

For supporting clinical colleagues in caregiving facilities, it is invaluable to know and understand the parameters to properly care for patients. Do we know what different blood sugar levels mean for specific patients? What is considered in range for normal, elevated or pre-diabetes? Do the results require immediate attention or just further monitoring? It is also imperative that all exams–eye, foot and dental–are given in the recommended time frame and that patients are up-to-date with all vaccines. Caregivers are critical to recognizing and managing potential issues because awareness is key.

Management of multiple medications becomes a challenge, particularly in elderly populations, where the number of prescribed medications commonly increases over time. This can result in a higher potential for drug interactions and negative side effects. The average person between the ages of 65 and 69 takes 14 medications, according to Health Research Funding. This intimidating number increases the likelihood of nonadherence simply because self-management becomes too difficult.

In January, the American Diabetes Association (ADA) released its 2017 guidelines. Much more emphasis was placed on prevention and delay of Type 2 diabetes. This was an important area of focus because there appears to be a lack of consistency amongst healthcare providers as to how and when blood sugar levels in the pre-diabetes range should be treated. To address this disparity, the ADA presented a practical risk assessment to help providers and patients understand who is more or less susceptible to developing diabetes. 

In addition to this assessment, physical activity guidelines include a recommendation that allow me to outline more realistic goals for my patients. I have frequently reminded my patients that in order to have a true and significant impact on blood sugars, it is recommended they perform 150 minutes per week of exercise with no more than two days without some form of activity. However, the guidelines also now state patients should interrupt prolonged sitting every 30 minutes to perform short bouts of physical activity. This is a practical standard most patients can meet regardless of age or ability.

Metformin is one of the most common drug therapy treatments for diabetes. The new guidelines emphasize long term use of Metformin can lead to Vitamin B12 deficiency. This has substantially influenced my medication review process, as I now ensure patients’ B12 levels are periodically monitored, and that supplements are prescribed when needed.

It’s an exciting time for diabetes treatment. Many new and innovative drug therapy options are becoming available to providers and patients. The need to continually bolster a provider’s treatment arsenal is a testament to the challenges associated with this disease.

When it comes to patients’ care teams, we should not overlook pharmacists as a substantial influence on patients’ willingness to advocate for their own health, particularly in promoting adherence to medications. After all, in the words of the late Surgeon General C. Everett Koop, MD, “Drugs don’t work in patients who don’t take them.”

Chuck Riepenhoff, RPh, CDE, is a clinical pharmacist at ProMedica Pharmacy Counter in Toledo, Ohio, where he has worked for more than 11 years supporting provider and employer-sponsored medication therapy management programs. He can be reached at chuck.riepenhoff@promedica.org.

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