The coronavirus disease 2019 (COVID-19) pandemic has yielded concerns among those with underlying conditions. Considering the high prevalence of chronic conditions within the United States, it is important to distinguish how each disease is impacted, individually, in order to determine what patients can do to stay healthy. Patients with chronic conditions that require frequent monitoring, such as diabetes, have especially been affected over the last few months of the pandemic.

Although the impact of COVID-19 on individuals with other conditions is relatively unknown at this time, there are actions that patients who have diabetes can take in order to maintain their health during this pandemic. There has been an abundance of information presented to the public during the pandemic that contains limited or questionable evidence, leaving both patients and professionals unsure of what to do in order to stay healthy. Pharmacists can assist patients with diabetes to ensure they are optimally managing their condition, and to potentially minimize the risk for complications associated with COVID-19.

Obesity, defined as a body mass index of 30 or above, is a major contributor to the development of diabetes, and is a risk factor for the progression and death associated with COVID-19 in hospitalized patients.¹ According to some anecdotal reports, stay at home orders and the encouragement of social distancing has caused Americans to gain weight.¹ Regardless of the current pandemic, lifestyle change is recommended as first line therapy for diabetes. Pharmacists play an important role in advising patients on physical and behavioral habits. The American Diabetes Association (ADA) recommends that obese patients address their dietary, physical and behavioral habits to achieve and maintain ≥5% weight loss.²

Pharmacists should recommend that all diabetic patients get at least 150 minutes of moderate to vigorous intensity exercise per week, going no more than 2 consecutive days without exercise in order to increase insulin action. In addition, the ADA recommends at least 2-3 sessions per week of resistance exercise on nonconsecutive days. It is important to keep in mind that these recommendations are targets that patients can gradually work up towards. The ADA highlights that aerobic exercise sessions should last at least 10 minutes, but recommends they be increased gradually up to 30 minutes or more most days of the week.² Pharmacists should encourage the patient to take part in certain exercises based on their disease state and comorbidities. For example, if the patient has osteoporosis, it would be appropriate to recommend light weight bearing activities, such as walking or hiking.

In addition to exercise, the ADA has specific recommendations for dietary changes to encourage healthy weight loss. A 500-750 kcal/day deficit can assist in the achievement of significant weight loss. This recommendation would typically yield a diet that provides 1,200–1,500 kcal/day for women and 1,500–1,800 kcal/day for men.³ Eating a balanced diet and understanding the impact of macro and micronutrients on blood sugar is essential for diabetic patients. Professionals need to educate patients on dietary concepts and the risk for hypoglycemia associated with weight loss. Weight loss can be difficult to achieve regardless of the prevailing pandemic; therefore, pharmacists should gauge what barriers each patient is experiencing in order to provide the most appropriate resources for a given situation. The use of evidence-based coaching techniques can be especially helpful during this process, including motivational interviewing.

As COVID-19 has caused many health care appointments to be postponed, many patients with diabetes have not been seeing their providers. Many patients have not had routine lab work completed for months and have been left wondering what actions they can take to optimally manage their blood sugar levels. Pharmacists have an opportunity to enhance their involvement in patient care because they remain the most accessible health care professionals.

Pharmacists should recommend that patients keep a log of their blood sugars on a daily basis and bring their results into the pharmacy for assessment. Although most pharmacies do not have the ability to perform routine A1C testing, an average blood glucose can provide significant information as to what a patient’s A1C is likely to be. By using resources supported by the ADA, pharmacists can infer where the patient may need therapy changes to improve their outcomes.⁴

Further, if the patient is willing, they should be encouraged to start keeping a dietary log, especially if they are counting carbohydrates. This provides additional data, and allows for more detailed recommendations by the pharmacist. When analyzing this data, clinical knowledge should be used to assess where the patient could benefit from therapy adjustments to improve their blood sugars. Hypoglycemia should be addressed first, followed by trends of high blood sugars. Once gaps in therapy or areas for improvement have been identified, pharmacists should use the current ADA guidelines to support their recommendations. Although many community pharmacists don’t have the authority to tell patients to change their medication regimen, they have the ability to reach out to providers and offer clinical reasoning to support their suggestions.

In addition to blood sugar monitoring, reviewing state immunization databases to determine which vaccinations patients are due for can potentially contribute to better outcomes during the ongoing pandemic. Based on CDC and ADA guidelines, it is appropriate to recommend that patients receive these vaccines the next time they are in the pharmacy to pick up their medications. This includes, but is not limited to, influenza, zoster, pneumococcal, hepatitis B, and tetanus-diphtheria vaccines.

During a time when many public statements regarding medication use are surfacing at a rapid rate, including some with minimal evidence to support the claims, pharmacists are a resource for addressing concerns or questions that patients with diabetes may have about their prescriptions and over-the-counter products.

Pharmacists also can manage potential drug shortages by anticipating that they may occur and closely monitoring inventory, and pharmacists should counsel patients about potential therapy changes.

The accessibility of pharmacists during the current pandemic has presented opportunities for these professionals to provide enhanced patient care for chronic disease management. By encouraging healthy habits, including physical activity and regular blood glucose monitoring, pharmacists can help improve the health of patients and minimize their concerns associated with COVID-19. Ultimately, the knowledge and training of pharmacists provides them with the skills to educate and assist patients in managing their health as it relates to COVID-19, especially diabetes.
 
Rita C. Hammer is a 2021 PharmD candidate, concentrated on Diabetes Management, at Drake University in Des Moines, Iowa. She was mentored on this article by Ashleigh Arndorfer, PharmD.


REFERENCES
  1. Selvin E, Juraschek SP. Diabetes Epidemiology in the COVID-19 Pandemic [published online ahead of print, 2020 Jun 15]. Diabetes Care. 2020;dc201295. doi:10.2337/dc20-1295
  2. American Diabetes Association. 5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43(Suppl 1):S48-S65. doi:10.2337/dc20-S005
  3. American Diabetes Association. 8. Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42(Suppl 1):S81-S89. doi:10.2337/dc19-S008
  4. Educational Materials for Your Patients: Know Your Numbers. NovoMedLink. https://www.novomedlink.com/content/novomedlink/en/diabetes-patient-support/disease-education.html?asset-tag-filter=Blood%20Sugar%20Tracking. Published May 2016. Accessed July 14, 2020.