Pharmacists are well-positioned to address diabetes from a multifaceted approach.
More than 38 million people have been diagnosed with diabetes as of 2021.1 Type 1 diabetes (T1D) is classified by autoimmune beta-cell destruction, causing insulin deficiency, whereas type 2 diabetes (T2D) is non-autoimmune in nature and is caused by a progressive loss of beta-cell function, leading to decreased insulin secretion, insulin resistance, and metabolic syndrome. Regardless of classification, tight control of diabetes is essential for preventing both micro and macrovascular complications. The American Diabetes Association Standards of Care in Diabetes has taken this prevention one step further, shifting focus to protection of these complications by revising recommended pharmacologic treatments.2 In particular, obesity, cardiovascular (CV) disease, and chronic kidney disease (CKD) have dedicated content sections to reflect evidence in medications shown to not only address blood glucose control, but these comorbid conditions.3-5
As obesity has been linked to an increased risk of T2D development, weight management is imperative. Guidelines address appropriate weight monitoring, provision of individualized nutrition and exercise counseling, and recommendations for glucagon-like peptide-1 receptor agonists (GLP-1 RAs).3 Table 16-9 reviews recommended GLP-1 RAs and their respective outcomes. Prior to initiation of a GLP-1 RA, medical history should be reviewed for presence of medullary thyroid carcinoma and/or multiple endocrine neoplasia syndrome type 2 as GLP-1 RAs are contraindicated with these disease states.2 Patients should be counseled on major adverse effects (AEs), including appetite suppression, weight loss, risk of pancreatitis, and gastrointestinal AEs such as nausea and vomiting. Such risks can be mitigated by eating smaller meals, limiting carbohydrate-heavy foods, and ensuring appropriate dose titrations at 4-week intervals.
Atherosclerotic CV disease is the primary cause of morbidity and mortality in patients with diabetes.4 Appropriate blood pressure monitoring and control, diet and exercise recommendations, and treatment options with proven CV benefit form the backbone of treatment. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) and GLP-1 RAs are recommended first line for reduction of CV risk, often with both therapies being appropriate in combination. Tables 2a7-13 and 2b14,15 summarize the CV data supporting the use of these agents. Patients should be counseled on potential AEs of SGLT2i, such as urinary tract infections or yeast infections, which can be mitigated with appropriate hydration and hygiene.2
CKD is the leading cause of end-stage renal disease and occurs in up to 40% of patients with diabetes.5 Guidelines recommend annual screening, frequent monitoring, and appropriate pharmacologic prevention with an SGLT2i following optimization of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy. Specifically, SGLT2i are recommended if a patient’s estimated glomerular filtration rate is greater than or equal to 20 mL/min/1.73 m2. GLP-1 RAs may also have a role in reducing CKD risk and are included in guideline recommendations (see Table 37-9,11-13,16-18).5
Collaborative Drug Therapy Management or Collaborative Practice Agreements
Given the complexity of and challenges associated with diabetes care, an interdisciplinary approach is ideal. Diverse strategies exist in integrating collective efforts to manage patients with diabetes. Collaborative drug therapy management (CDTM) and collaborative practice agreements (CPAs) are 2 frameworks that allow pharmacists to provide expanded patient care services, particularly in managing chronic conditions such as diabetes.
CDTMs are more focused, specifically authorizing pharmacists to manage and modify drug therapy, including initiating, adjusting, or discontinuing medications for diabetes. A CDTM for diabetes management would primarily involve a pharmacist adjusting insulin doses, modifying oral diabetes medications, and ordering related laboratory tests. Alternatively, CPAs are broader agreements that can encompass a wider range of clinical services beyond medication management, such as ordering laboratory tests, performing physical assessments, and providing comprehensive diabetes education and care planning. A CPA might include these medication-related activities but also allow the pharmacist to perform foot examinations, provide detailed lifestyle counseling, make referrals to specialists, and take a more comprehensive approach to the patient's diabetes care. The choice between CDTM and CPA often depends on state regulations, practice setting capabilities, and the desired scope of pharmacist services.19
To effectively implement a CDTM or CPA, several key practices are essential. It is important to create a protocol that clearly outlines the scope of services and helps guide clinical decision-making. Establishing standardized documentation templates ensures consistency in care delivery and supports quality assurance efforts. Lastly, identifying a set of quality metrics that capture clinical outcomes, such as change in hemoglobin A1c, can demonstrate the program's value.
The Pharmacist’s Role
Rebecca Chapin, PharmD, BCACP, is an ambulatory care clinical pharmacy specialist at the Medical University of South Carolina Health.
Jacob Coomes, PharmD, is an ambulatory care clinical pharmacy specialist at the Medical University of South Carolina Health.
Emmeline Tran, PharmD, BCPS, is an ambulatory care clinical pharmacy specialist at the Medical University of South Carolina Health and an associate professor at the Medical University of South Carolina College of Pharmacy.
From more traditional models focused on medication education to the expansion of clinical services via comprehensive disease state management, the role of the pharmacist within diabetes care continues to evolve. Expertise in pharmacotherapy coupled with the status of “most accessible health care professional” place pharmacists in a unique position to optimize patient care. The positive impact of pharmacists on both clinical and nonclinical outcomes has been demonstrated.20
As with any disease state, the core of a pharmacist’s role in diabetes care is education. Educational interventions typically include lifestyle modifications; risk reduction; self-monitoring; and medication administration, adherence, and AEs. Furthermore, pharmacists contribute to providing credible health information, including debunking misinformation provided to the public.
Beyond education, pharmacists participate in the management of diabetes through provision of evidence-based recommendations for medication selection, modification, and monitoring, and health maintenance screening. Pharmacists are positioned to balance the complexities of other disease states impacting diabetes management to provide more integrated care.
Expanding access to care is another central aspect in the role of a pharmacist. Pharmacists may act as extenders to provide care in between appointments with primary care providers and or endocrinologists, especially given provider shortages in these specialties. Additionally, pharmacists may also facilitate care with or referrals to other providers and health care professionals acting as patient advocates to address concerns both related and unrelated to diabetes. Moreover, pharmacists play an integral role in medication, device, or supplies access through navigation of drug shortages and facilitation of coverage of these therapies. Simple miscommunication or misunderstanding can result in patients being unable to acquire needed therapies.
In addition to providing individualized patient management, pharmacists also play a significant role in population health initiatives within diabetes care, such as prevention, screening, and immunizations.
Diabetes care has evolved significantly with the introduction of medications that address both blood glucose control and common comorbid conditions. Moreover, the advancement of practice has allowed for innovative ways for managing patients with diabetes. Considering the multifaceted nature of diabetes, collaboration is critical to ensure optimal outcomes. Core team members in this collaborative effort include pharmacists whose roles encompass education; disease state screening, prevention, and management; and access to care.
