Navigating Patients Through T2D Therapy in the Pharmacy

APRIL 29, 2019


Advice for community pharmacists on how to work with patients and their physicians to optimize therapy.


Troy Trygstad, PharmD, MBA, PhD: So let’s go back to the scenario in which I’m in a community pharmacy. I’ve had a relationship with patient A for 20 years. They’ve been on metformin. I’ve noticed over the time that I’ve had a relationship with this patient that they’re not losing weight. They’re gaining weight. They’re also on some cardiovascular agents. When I have the conversation with the patient—you know, “Well, I don’t know what my hemoglobin A1C [glycated hemoglobin] is,” but they might know, and it’s probably high—what do I do in that circumstance? If I don’t have a Dr. Patel right down the road from me, where I can refer them directly, how do I broach that conversation with that patient to say, “You know, I don’t know what your current course of therapy is or what your current relationship looks like with your existing provider, but it might be worthwhile to have a conversation about maybe trying something new.” What is that best trigger advice you would give to a community pharmacist out there, or to some of your brothers and sisters in physicians’ clinics, where you’d say, “This is a good trigger or way to know that we really ought to reset this patient”? And then how do you start or broach that conversation?

Jessica L. Kerr, PharmD: With the patient?

Troy Trygstad, PharmD, MBA, PhD: Yes.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: I would say to just ask them. Sometimes it’s asking, or having that conversation. “Were you satisfied? Are you happy with the treatment?” And then that’s when you start peeling the different layers of the onion.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: You would say, “What are your thoughts about advancing your treatment? What do you think about adding another medication to your regimen? With this medication, although it’s working, there’s still some room for improvement. What are your thoughts about adding something else?”

Oftentimes patients have the misconception of, “I have 1 disease state. I take 1 pill to fix that problem.” So they don’t understand the need for 2 drugs. We started out talking about 8 broken organs. There’s not 1 drug therapy that fixes all 8. So right there, combination therapy is somewhat inevitable. And now true, the combination therapy could include lifestyle, but oftentimes will include at least dual or triple medications. And so it’s about having that conversation with the patient of, “What are your thoughts about this?”

And I think probably the bigger challenge is when it comes to injectables. “So what do you think about injectables?” And of course we have the patients who are like, “Oh, no. I don’t want to do that.” “What is it about a needle or the injectable device that has you worried? What is it that you’re scared of?” So it’s about exploring the patient understanding and willingness and then working with them to overcome that.

Jessica L. Kerr, PharmD: Yeah. And another thing is, you’ve known this patient for 20 years, right? So you’ve had other conversations just generally about life. It might be that the newest thing kind of gets them excited. Or technology or, “Did you hear about his new study that just came out that is looking at this?” And that’s how you start talking about some of the advances in therapies. And then if they can see how it could improve some of their disease state, it may even improve their compliance. If you have a patient who is on a basal bolus insulin, and these GLP-1s [glucagon-like peptide-1 agonists], they’re not even really taking the 3-times-a-day bolus insulin, or they’re still on 20, 30 units, 3 times a day, and it’s very feasible that with just 1 shot a week, we could try to get rid of all those mealtime shots and work from there.

Troy Trygstad, PharmD, MBA, PhD: So let’s say I’ve gotten the patient now to a state of readiness, because whatever we’ve been doing for 20 years isn’t working. It’s not a responsibility of mine to disrupt an existing care process. I have a patient presenting to me who isn’t doing so well, and they haven’t been doing so well. I have a professional obligation to say, “Hey, you know what? Maybe it makes sense to reset a little bit here and to rethink this.” So if I get to them to that state of readiness, how do I approach the other care-team members? Or do I put that on the patient? Do I prompt it? What would be a best practice if a patient says, “Yeah, you know what, I’m willing to think about this differently. If there are some new ways to approach this or I need to reset, I’m ready for that.” Now what do I do, as a practitioner out there in the community, either to get them back to you or to broach that conversation with a care-team member?

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Well, having been a community pharmacist for 20 years, I know that 1 of the things we had in our pharmacy was an American Diabetes Association–recognized education program. This is very unusual for pharmacies, but there are several out there that have this. So 1 of the things is when we would meet with our patients, yes, to a degree some of the onus was put back on the patient. It is their condition. And if they show interest in managing it, it does help. So we would do that. But at the same time, we would send a letter or an e-mail or a fax, or sometimes we would even do a phone call to the doctor to say, “Hey, doc, I’ve got your patient here. This is how they’re doing. What are your thoughts on adding drug A or drug B or whatever to their regimen to help them get under better control?”

And, again, this is where it does take community pharmacists to that next level of being part of that plan, to actually create that care plan that’s appropriate for the patient.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Yeah, I would agree. And with the amount of information that you have on your end, because you have prescription data, you have adherence data, you’ve noticed that in the last year their sulfonylurea was filled 6 out of the 12 months. “Why is it that you don’t take this on a consistent basis?” “Well, it causes weight gain. They told me to take 10 mg twice a day, and I take 10 mg only because I started noticing weight gain.”

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Or they have hypoglycemia from it.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: It can be any 1 of those. And so when you make that call, now you have some additional information. It’s not just, “You know, someone came by the pharmacy and dropped this off. It’s a new drug, and I think it would work for them.” Or, “Last year they took only 50% of their medications, and it was mainly because of hypoglycemia or weight gain. They were the biggest issues. This drug is given once a week or once a day, and it doesn’t have this profile. I think it would probably be worthwhile to recommend to this patient.”

Susan Cornell, PharmD, CDE, FAPhA, FAADE: I think what’s also an opportunity for community pharmacists, when we go back to time in range, more and more continuous glucose monitors [CGMs] are going to be made available with a prescription but through the pharmacy. As we start to see the pharmacist counsel patients on their CGM, there are also data that come with it. And 1 of the things that we used to do in community pharmacy—we would do this back in the day with blood glucose meters—is download that data. You could make an assessment of the time in range and where treatment adjustments need to be done, as we all do in clinical practice. But this could be done in the community setting.

And then with that information, you send it to the doctor or prescriber with your recommendation for whatever change you want. So you have data to support your recommendation.

 


Advice for community pharmacists on how to work with patients and their physicians to optimize therapy.


Troy Trygstad, PharmD, MBA, PhD: So let’s go back to the scenario in which I’m in a community pharmacy. I’ve had a relationship with patient A for 20 years. They’ve been on metformin. I’ve noticed over the time that I’ve had a relationship with this patient that they’re not losing weight. They’re gaining weight. They’re also on some cardiovascular agents. When I have the conversation with the patient—you know, “Well, I don’t know what my hemoglobin A1C [glycated hemoglobin] is,” but they might know, and it’s probably high—what do I do in that circumstance? If I don’t have a Dr. Patel right down the road from me, where I can refer them directly, how do I broach that conversation with that patient to say, “You know, I don’t know what your current course of therapy is or what your current relationship looks like with your existing provider, but it might be worthwhile to have a conversation about maybe trying something new.” What is that best trigger advice you would give to a community pharmacist out there, or to some of your brothers and sisters in physicians’ clinics, where you’d say, “This is a good trigger or way to know that we really ought to reset this patient”? And then how do you start or broach that conversation?

Jessica L. Kerr, PharmD: With the patient?

Troy Trygstad, PharmD, MBA, PhD: Yes.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: I would say to just ask them. Sometimes it’s asking, or having that conversation. “Were you satisfied? Are you happy with the treatment?” And then that’s when you start peeling the different layers of the onion.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: You would say, “What are your thoughts about advancing your treatment? What do you think about adding another medication to your regimen? With this medication, although it’s working, there’s still some room for improvement. What are your thoughts about adding something else?”

Oftentimes patients have the misconception of, “I have 1 disease state. I take 1 pill to fix that problem.” So they don’t understand the need for 2 drugs. We started out talking about 8 broken organs. There’s not 1 drug therapy that fixes all 8. So right there, combination therapy is somewhat inevitable. And now true, the combination therapy could include lifestyle, but oftentimes will include at least dual or triple medications. And so it’s about having that conversation with the patient of, “What are your thoughts about this?”

And I think probably the bigger challenge is when it comes to injectables. “So what do you think about injectables?” And of course we have the patients who are like, “Oh, no. I don’t want to do that.” “What is it about a needle or the injectable device that has you worried? What is it that you’re scared of?” So it’s about exploring the patient understanding and willingness and then working with them to overcome that.

Jessica L. Kerr, PharmD: Yeah. And another thing is, you’ve known this patient for 20 years, right? So you’ve had other conversations just generally about life. It might be that the newest thing kind of gets them excited. Or technology or, “Did you hear about his new study that just came out that is looking at this?” And that’s how you start talking about some of the advances in therapies. And then if they can see how it could improve some of their disease state, it may even improve their compliance. If you have a patient who is on a basal bolus insulin, and these GLP-1s [glucagon-like peptide-1 agonists], they’re not even really taking the 3-times-a-day bolus insulin, or they’re still on 20, 30 units, 3 times a day, and it’s very feasible that with just 1 shot a week, we could try to get rid of all those mealtime shots and work from there.

Troy Trygstad, PharmD, MBA, PhD: So let’s say I’ve gotten the patient now to a state of readiness, because whatever we’ve been doing for 20 years isn’t working. It’s not a responsibility of mine to disrupt an existing care process. I have a patient presenting to me who isn’t doing so well, and they haven’t been doing so well. I have a professional obligation to say, “Hey, you know what? Maybe it makes sense to reset a little bit here and to rethink this.” So if I get to them to that state of readiness, how do I approach the other care-team members? Or do I put that on the patient? Do I prompt it? What would be a best practice if a patient says, “Yeah, you know what, I’m willing to think about this differently. If there are some new ways to approach this or I need to reset, I’m ready for that.” Now what do I do, as a practitioner out there in the community, either to get them back to you or to broach that conversation with a care-team member?

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Well, having been a community pharmacist for 20 years, I know that 1 of the things we had in our pharmacy was an American Diabetes Association–recognized education program. This is very unusual for pharmacies, but there are several out there that have this. So 1 of the things is when we would meet with our patients, yes, to a degree some of the onus was put back on the patient. It is their condition. And if they show interest in managing it, it does help. So we would do that. But at the same time, we would send a letter or an e-mail or a fax, or sometimes we would even do a phone call to the doctor to say, “Hey, doc, I’ve got your patient here. This is how they’re doing. What are your thoughts on adding drug A or drug B or whatever to their regimen to help them get under better control?”

And, again, this is where it does take community pharmacists to that next level of being part of that plan, to actually create that care plan that’s appropriate for the patient.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Yeah, I would agree. And with the amount of information that you have on your end, because you have prescription data, you have adherence data, you’ve noticed that in the last year their sulfonylurea was filled 6 out of the 12 months. “Why is it that you don’t take this on a consistent basis?” “Well, it causes weight gain. They told me to take 10 mg twice a day, and I take 10 mg only because I started noticing weight gain.”

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Or they have hypoglycemia from it.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: It can be any 1 of those. And so when you make that call, now you have some additional information. It’s not just, “You know, someone came by the pharmacy and dropped this off. It’s a new drug, and I think it would work for them.” Or, “Last year they took only 50% of their medications, and it was mainly because of hypoglycemia or weight gain. They were the biggest issues. This drug is given once a week or once a day, and it doesn’t have this profile. I think it would probably be worthwhile to recommend to this patient.”

Susan Cornell, PharmD, CDE, FAPhA, FAADE: I think what’s also an opportunity for community pharmacists, when we go back to time in range, more and more continuous glucose monitors [CGMs] are going to be made available with a prescription but through the pharmacy. As we start to see the pharmacist counsel patients on their CGM, there are also data that come with it. And 1 of the things that we used to do in community pharmacy—we would do this back in the day with blood glucose meters—is download that data. You could make an assessment of the time in range and where treatment adjustments need to be done, as we all do in clinical practice. But this could be done in the community setting.

And then with that information, you send it to the doctor or prescriber with your recommendation for whatever change you want. So you have data to support your recommendation.

 
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