Experts Dhiren Patel, PharmD, CDE, BC-ADM, BCACP, and Javier Morales, MD, review key understandings for both patients and providers regarding the optimal management of type 2 diabetes, including considerations for patient education, micro- or macrovascular complications, and multidisciplinary approaches.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: When talking to patients about type 2 diabetes as pharmacists, it’s important to make sure the counseling is comprehensive but not overwhelming. What I mean by that is there are a lot of aspects in diabetes care, especially with type 2 diabetes, that patients will have to take into consideration. For example, medication adherence is one. Others include immunizations and self-care management skills, so there are a lot of different things that are going to be important. But again, it’s important to make sure that pharmacists don’t overwhelm the patient.
Sometimes, the patients could have just received a diagnosis of that condition. They know very little. It might include just explaining to them what’s happening with their body and why they may be on 1 or 2 different medications to treat the same condition. Sometimes, just explaining how a drug works makes a big impact because they now understand why they’re taking that drug. For example, it could be an oral pill or an injectable. Sometimes, they may not understand those differences and why some patients or friends of theirs are on oral medication versus an injectable. That impacts adherence and persistence rates and makes sure patients understand what they’re doing.
The other things are a lot of lifestyle and behavioral changes. With any chronic condition, it’s important to talk to patients regarding lifestyle changes they can make. From a pharmacist’s standpoint, that could involve things such as smoking cessation—if that’s applicable‑ proper amounts of alcohol intake, nutrition, and exercise. There are some examples. Oher self-care management items that would be on that list are proper foot care, proper immunizations—as I mentioned earlier—and the treatment of hypoglycemia, and what to do in those emergency situations.
There are a lot of different things, but it’s a relationship that the pharmacist and that patient are going to have and build on. In the beginning it’s, “What do they need to know today?” And then it’s, “What are things that I can talk to them about as this relationship builds?”
Javier Morales, MD: The microvascular complications associated with type 2 diabetes include proliferative retinopathy; nephropathy, which involves the kidneys and loss of protein and irreparable damage; and peripheral neuropathy. Peripheral neuropathy is interesting though, because there are 2 different types. You have one that we call “painful neuropathy” and another one that we call “position-sensitive neuropathy.”
The macrovascular complications associated with type 2 diabetes and type 1 diabetes are centered on heart disease, increased risk for myocardial infarction, cardiovascular death, and stroke. Tight glycemic control is advocated because in the long term, microvascular complications tend to progress a little bit slower in those who exhibit tight glycemic control. Likewise, tight glycemic control may in part cause not a short-term benefit on macrovascular risk reduction, but perhaps a legacy effect that can be seen many, many years later in those who are more intensively treated.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: The way that I work and the clinical capacity that I have is in a multidisciplinary team. We know that when it comes to managing a patient with diabetes, it’s going to require a lot of time and effort and resources. I always joke around and say that it takes a village to manage a patient with diabetes. The reason being is if there was just an endocrinologist or a primary care physician who could treat and solve a lot of the issues that we have with diabetes, it wouldn’t be in the current state that it is. So, we need all hands on deck.
In my clinic, the way we have it integrated is that we have 3 endocrinologists, a nurse practitioner, and myself. We work with our primary care colleagues to take referrals and counsels from them because we realize that there’s a lot on their plate. We try to focus on their endocrine-related or diabetes-related matters. But again, make sure that you have a multidisciplinary team. Or, if you don’t have access to a team in all situations, at least make sure that you care coordinate some of those services. We don’t have a nutritionist or a dietician that sits directly on our team, but we make sure that they’re aware of the treatment plans they’re being referred to, and the same thing goes for the pharmacist.
You might be helping the patient make an appointment with one of the specialists. It’s important to care coordinate that back to their provider if there are medication changes or if you notice that there’s a certain medication that their patient is no longer taking because of an adverse reaction that they’ve informed you about. These are all important things that you need to let the entire team that’s managing that patient and that patient’s condition know.