Ferkhanda Najib, PharmD

Diabetes is a complex disease, with multiple strategies involved in disease management. Along with lifestyle modifications and medications, diabetes management also includes blood glucose monitoring for those patients who must maintain more precise control over their glucose levels.

Glucose meters are useful for patients with both type 1 and type 2 diabetes. There are several brands and types of meters on the market, and patients can easily become overwhelmed by the choices. The best choice is dependent on many factors, including accessibility, affordability, and preference of features. Often patients’ insurance plans will dictate the selection, as possibly only one brand will be on the formulary. Medicare covers most of the cost of select diabetic testing supplies with a doctor’s prescription.

Diabetic patients often need to check their blood sugar to get an idea of how well their pharmacologic interventions are working, with sometimes patients needing those blood sugar checks to determine how much insulin to inject themselves with. By checking their blood sugar often, patients can measure the effectiveness of their lifestyle modifications. Then, by gaining insight into how much a particular meal affects their blood sugar, they can learn what foods they can and should avoid.

Today, the traditional fingerstick method is still the predominantly used glucose monitoring method. A sample of blood is placed onto the test strip, which is inserted into and read in 5 seconds by a handheld meter. These meters, which can store on average 250 to 300 readings, are small enough to fit in a purse and usually come in a small carrying case.

The case can hold a supply of lancets, which are the needles used to prick the finger; the lancing pen; the meter; alcohol swabs; and a vial of test strips. The lancing pen is loaded with a lancet with which the puncture depth can be selected. It is recommended to select the level with the least discomfort that yields a drop of blood large enough to drench the test strip. If the sample is not large enough, an error message will display in the meter.

With this traditional fingerstick method, the most common complaint pharmacists receive from patients is that they don’t want to prick their fingers anymore. Even though the sample required is very small, it is a highly disliked procedure among patients, and particularly among elderly individuals or pediatric patients for whom this method can be especially difficult.

The cost of the meters typically range from $10 to $25. However, the hidden cost is the price of the test strips, which range from about $50 to $125 per 100 strips. Depending on how many times per day patients are required to test their blood sugar, this cost can easily add up and become a burden on their overall disease management.

Each brand has its own test strips; unfortunately, a strip from one brand will not fit or work with a meter from another brand. These meters vary based on the number of readings they store and how fine the gauge is on the lancet they come with, as well as other factors. However, patients can use a lancing device and lancets of a different brand than the meter and test strip; only the test strips and meters have to match.

A common prescribing error occurs when the physician is unaware of the brand the patient has previously used and writes a prescription for continuing test strips of another brand, which will not work with the patient’s meter. If the patient is new to the pharmacy, the pharmacy will fill the brand written by the physician. Fortunately, it is common practice for pharmacists to ask patients which brand of machine they use prior to dispensing their diabetic supply prescriptions.

The meters, test strips, and lancets are each sold separately. The different brands available include OneTouch Ultra, OneTouch Delica, Contour, Bayer Ascencia, Freestyle, Easy Touch, Relion, True Metrix, and CareTouch—to name a few. These basic meters are accurate and simple enough for anyone to use.

When patients are first prescribed a meter, pharmacists can take the opportunity to counsel the patients on how to use a control solution to maintain their meter and talk them through the initial setup. It is a good tip for patients to always keep the meter case packed with supplies like alcohol swabs, strips, lancets, and control solution.

This feature allows a meter to transmit glucose readings to a smartphone. Many basic fingerstick-style glucose monitors and those with advanced features offer this technology, which can be beneficial in tracking glucose levels and conveniently storing the readings in one place to present during doctors’ visits. It can also present readings in chart form to show trends, which may help a patient realize how certain behaviors or food choices influence their blood sugar reading. Generally, this feature is appropriate for patients who like to track their health and disease management using their phone.

Continuous glucose monitoring (CGM) systems now provide the long-awaited option for diabetes patients to not have to prick their fingers for each test. This new technology, which can take readings every 5 minutes, includes the Bluetooth feature, and offers even further insight into managing blood glucose levels. Patients can also see instant changes in their sugar levels in correlation to their food choices, stress, sleep, and other lifestyle choices.

This meter also comprises a sensor device, which is affixed to the patient’s arm, and a reader device to which the sensor sends the reading. Utilizing this type of meter not only helps to manage one’s glucose levels, but it can be set up to give an alert on a preselected glucose level. In other words, you can get alerts when your sugar is too high or too low.

Among the CGM readers, there are variations in use, such as how the Freestyle Libre CGM reader requires smartphone scanning while the Dexcom reader does not. Additionally, the Dexcom reader can be used for patients aged 2 years and older, while the Freestyle Libre 14-day system is approved for patients aged 18 years and older. Further, there is a Freestyle Libre 2 available, which is a new version that is approved for patients aged 4 years and older. However, the Dexcom CGM monitor is more ideal for those using insulin pumps.

The major drawbacks to the CGM method are its cost and patients’ ability to troubleshoot when problems arise with the readers’ functionality. Common feedback pharmacists receive is that the sensor does not stay on, which is particularly concerning since once it falls off, it should not be reinserted into the patient’s body. Initially, this was a major concern, but systems now come with adhesive bandages that have significantly improved the use of the patch. Each sensor should be replaced every 10 days or 2 weeks, depending on the instructions.

The sensors cost on average $75 to $100 for a pack of 2. Unless covered by insurance, this can be quite costly to maintain. With a doctor’s prescription, pharmacists can tell patients if their meter will be covered on Medicare or their insurance plan. Additionally, in terms of patient selection for each meter, the CGM meter is particularly practical for use in the pediatric population.

Pharmacists can help patients with type 1 and type 2 diabetes navigate through the diabetes management choices available for them or counsel patients on best practice for their chosen meters. Furthermore, frequent glucose testing or monitoring can lead to patients having a clear awareness of the impact of their lifestyle choices on their disease state, which can help them make decisions around how to bring down A1C levels.

, is a client relations pharmacist and vaccine coordinator for Community Care Rx, a full-service, long-term care pharmacy with offices in Hempstead, NY and Totowa, NJ.

Articles

For patients with type 1 and type 2 diabetes, decisions around the selection of glucose meters can be difficult as there are several brands and types of meters available. 

Pros, Cons of Different Diabetes Monitoring Devices, How Pharmacies Can Support Optimal Use

Reports of depression, anxiety and stress have surged since the beginning of the COVID-19 pandemic in 2020. In a Kaiser Family Foundation (KFF) poll in February 2021, 4 out of 10 Americans reported that they were experiencing symptoms of anxiety disorder or depressive order, compared with 1 out of 10 in January 2019.

The spike in adverse mental health symptoms has led to increased use of behavioral health medications. This, in turn, has resulted in more patient questions and concerns and an expanded need for monitoring to ensure that these medications do not interact poorly with other medications.

Over the last year and a half, certain segments of the population have suffered more adverse mental health consequences than others. Social distancing and remote schooling significantly impacted the lives of young adults, who reported higher levels of mental health symptoms than other age groups. According to KFF data, 25% of young adults said they had started or increased substance use during the pandemic, compared with 13% of all adults. The absence of in-person school, sports, and other recreational activities also significantly changed the lives of youth and their parents, making it difficult for them to cope.

Racial and ethnic minorities, essential workers, and unpaid adult caregivers also reported disproportionately worse mental health symptoms, increased substance use, and elevated suicide ideation, according to the KFF report.

Although rates of COVID-19 infections are generally improving, history has shown that the mental health toll from pandemics and other disasters can last well beyond the physical impact. For instance, studies show that previous outbreaks have caused increased mental health concerns for health care workers up to 3 years after the outbreak itself.

Pharmacists play an important role in helping patients navigate behavioral health medications. Throughout the pandemic, pharmacists have been the most accessible health care professionals. They have been readily available to patients to answer day-to-day questions and provide accurate guidance.

Patients are frequently concerned about how over-the-counter medications will interact with their drug regimen. Pharmacists can answer questions as well as advise patients on when they need to seek medical advice or further follow-up from their primary care physician. They can also guide patients on what to expect with a medication, such as whether something is a common adverse effect or a more serious adverse effect that should not be ignored.

Given accessibility, time, and resources, pharmacists have the clinical knowledge to perform medication therapy management (MTM) services and pharmacy reviews to provide patients with optimal health care and cost-saving solutions. They can assess the risks of polypharmacy, which refers to the regular use of 5 or more medications or visiting multiple doctors.

The pharmacist is also the link between the patient’s voice and the prescriber and insurance company. Pharmacists often find themselves advocating for a patient when the initially prescribed medication is either not covered by insurance or if it is producing intolerable side effects. Consequently, pharmacists can also be the ones to further explain in detail to a patient why an alternative drug may be the best option.

Pharmacists are required to continue their education and keep up to date with the new medications on the market. Pharmacists can also pursue further education and residency in psychiatry, leading to greater collaboration with the prescriber and nurses with the goal of achieving the best health outcomes for the patient.

 is a Client Relations Pharmacist, Vaccine Coordinator and Consulting Pharmacist for Community Care Rx, a full-service, long-term-care pharmacy with offices in Hempstead, N.Y. and Totowa, N.J.

Panchal N, Kamal R, Cox C, and Garfield R. The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation; February 10, 2021. Accessed November 18, 2021. 

https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/

Reports of depression, anxiety and stress have surged since the beginning of the COVID-19 pandemic in 2020. 

Pharmacists Can Help Meet the Need for Increased Behavioral Health Medication Management  

The surging Delta variant and news of breakthrough infections have sparked considerable interest in COVID-19 booster shots. The FDA recently authorized third shots for immunocompromised individuals, who comprise about 3% of the US population.

Questions about when booster shots will be recommended for the general population are sure to intensify in the coming weeks, and the only answer pharmacists can give is: “Not yet.”

Israel has already begun offering booster shots to all fully vaccinated individuals 60 years of age and over, citing rising infections and signs that the vaccines’ efficacy is dwindling over time. Moderna announced last week that people who had 2 doses of its vaccine will begin needing boosters by the fall.

A recent non-peer reviewed study at New York University suggested that the 1 dose of the Johnson & Johnson (J&J) vaccine may not offer enough protection against the Delta variant. San Francisco recently announced it will offer booster shots to people who received a J&J vaccine and who have consulted with a physician.

But the CDC does not currently recommend boosters for most fully vaccinated individuals. This guidance applies to people who received both doses of either the Pfizer-BioNTech or Moderna vaccine or the single-dose J&J vaccine.

 boosters are not yet indicated, it is likely that the CDC will recommend them in the not-so-distant future, given the fact that we are still battling the virus and there is now a surplus of supply in the United States. The rising cases of infection from the Delta variant may not allow time for studies to confirm the benefit of the third dose and the decision to implement booster shots might be rushed on this basis.

But for now, when someone requests a COVID-19 vaccine, we as pharmacists must determine whether the vaccination is appropriate for the individual—as we do whenever we vaccinate for the flu, shingles, pneumonia, etc. This includes asking patients whether they have had a COVID-19 shot already.

Although this information may be available in state and city databases, there have been data entry omissions, particularly for patients vaccinated in temporary pop-up clinics. You should follow good screening practices and question customers about whether they have been vaccinated before.

If patients have already been vaccinated but want a booster, you can educate them about the current guidance or you can also refer them to their physician. San Francisco has put the onus on physicians to decide whether a booster shot is appropriate, given their patients’ individual situation.

In addition to not knowing when booster shots will be recommended for the general population, we also do not know how they will be rolled out. We do not have the significant shortage of supply that we had in the first round, but this round is likely to be implemented in systematic phases that put front-line workers and the elderly next in line after the immunocompromised.

Another question that needs to be answered is whether individuals should receive the same brand of vaccine that they received the first time. Rather than mixing, say, Moderna and Pfizer, it is likely that staying with the same series will be recommended.

There have not been any studies to determine whether there are any benefits to changing between the series unless someone was suspected to be allergic to any of the components of vaccine after administration. Guidance on this matter will likely be announced when the boosters are recommended.

As more workplaces require that their employees be vaccinated, there may be increased demand for first-round COVID-19 vaccinations while booster shots are rolled out, putting heavy demand on pharmacies. Fortunately, pharmacies gained valuable experience from going through the first mad rush.

We know what to expect in terms of the level of manpower needed, including extra technicians and especially clerical staff to check customers in and out and process their paperwork. Pharmacists will benefit from having gone through this prior experience when boosters are finally approved and rolled out.

Ferkhanda Najib, PharmD is a pharmacy manager for Community Care Rx, a full-service, long-term-care pharmacy with offices in Hempstead, N.Y. and Totowa, N.J.

The FDA recently authorized COVID-19 vaccine booster shots for immunocompromised individuals, who comprise about 3% of the US population. 