Troy Trygstad, PharmD, MBA, PhD; Tripp Logan, PharmD; and Dhiren Patel, PharmD, highlight some of the prompts for intensification of therapy for the treatment of diabetes, and the role of the community pharmacist in educating patients on diabetes care.
Troy Trygstad, PharmD, MBA, PhD: Tripp, this is the “If it ain’t broke, don’t fix it,” conundrum, or problem, that you even see in a community pharmacy a lot, which we’ve discussed prior. What’s the prompt that leads to the reassessment or the trigger for the conversation for intensification of therapy? We can’t just have the assumption that we’ve got this therapy, it’s 5 years later, and that perfectly adherent patient, which is quite rare, is stable. Everything is good. There is no need for intensification, so nobody really looks into it a whole lot. How many of those folks do you suppose you have, who are walking into your pharmacy, every day, who aren’t interfacing with anybody that might say, “Hey, let’s take a look at that because you’re getting older.” Everybody gets older. “Is your disease state progressing?” Do we have a need for this? What’s the prompt for that? Do you see a lot of patients where you say, “It might make sense for us to just re-evaluate what’s going on?”
Tripp Logan, PharmD: Sure. One of the key factors is the legitimate fear that a lot of patients have of a hypoglycemic episode. And that’s amplified with people who have had one. From one standpoint, we recommend this more intensive standpoint. And then, from a pharmacist’s standpoint, what if they have a hypoglycemic episode? For any of us who have had those conversations with people, in a really tragic situation, as rare as they are, it’s very scary. Even getting those people engaged in their original care plan, or even adjusting it back upward, is tough. So, it’s delicate. When we’re talking about individualized care, it really is.
Dhiren Patel, PharmD: One other thing to add to that is, in our practices, now, because of this new cardiovascular data that we have with some of these diabetes agents, we’re not just putting a patient on that medication for their glycemic control. This is, again, a shortcoming of the guidelines. I could have a perfectly controlled patient. I know that some of these medications have positive cardiovascular data. We know about a couple of the GLP-1s, such as liraglutide and semaglutide, and a couple of the SGLT2 inhibitors. I might take a perfectly controlled patient and put him or her on this. It might require modifying, a little bit; or, in some cases, adding something just for the cardiovascular risk reduction and for zero glycemic benefit purposes. So, just to say that the A1C is the measure that we should go by—it just doesn’t make sense.
Troy Trygstad, PharmD, MBA, PhD: Tripp, I want to go back to you again. You’re from a small town in Missouri. Everybody knows each other. Let’s pretend, for a second, that there are 3 practices in town. Practice 1 adheres to one level of hemoglobin A1C. Practice number 2 adheres to another level of hemoglobin A1C. Practice 1 and practice 2 generally both do diabetes and cardiovascular care. Practice 3 adheres to 1 of the 2 levels of hemoglobin A1C, but they send everybody with cardiovascular disease to a cardiologist who is an hour away. Here you are, in the pharmacy. You serve all of these patients. What’s the role of that community pharmacy, in working with these patients, when you’ve got 3 different care coordination, types-of-practice scenarios? And what’s the role of yourself and your community in having frequent discussions in a professional manner? Do you work with each one of these in an individual way? Or, do you do some education and say, “Hey, here’s where we’re all at with this, and here’s what my opinion is,” and try to influence it all?
Tripp Logan, PharmD: Even to take a step back, it’s really hard to know which set of guidelines the prescriber was adherent to in the first place. It’s not like it’s on the prescription. We don’t even typically have a diagnosis code.
Troy Trygstad, PharmD, MBA, PhD: Why is that not the case?
Tripp Logan, PharmD: I don’t understand it. The prescription should have a diagnosis code, a potential goal, and the last 3 A1Cs, as far as I’m concerned. But, that’s not what we get. So, we’re in a tricky place, in trying to reconcile all of these things and maintain relationships. We’re care providers as well. We have to adopt some standard, within our practice, as well. So, how do we reconcile that? The only answer I have is, delicately.
Dhiren Patel, PharmD: You can’t get these prominent bodies to agree, then, let alone, can you imagine what….
Tripp Logan, PharmD: And then, be up to date at the same time, right?
Dhiren Patel, PharmD: Right.
Tripp Logan, PharmD: This stuff is changing regularly. We’re having this whole panel on it.
Dhiren Patel, PharmD: I think there’s a statistic out there that says that it takes, on average, 7 years, for something that’s been changed, to get into practice. And the literature turns around every 5 years. And so, you have more mixed messages that come out like this: “This should be the goal. That should not be the goal.” And sometimes, you’re just going to hear what you want to hear, based on what works best for your situation. “If I look at it and segment all of my patients at an A1C of around 8%, everyone is controlled. Let’s go with that.”
Troy Trygstad, PharmD, MBA, PhD: Well, we’re not going to solve that controversy today. We’re not going to solve community-based coordination today. But, we do have patients who have hemoglobin A1Cs of 10.8%, and have a history of myocardial infarction, and so on, and so forth. Dr. Patel, what are the practical considerations in cardiovascular risk reduction? If you’ve got a patient in front of you who needs hypertensive control, with diabetes, what’s your general approach to therapies and the considerations for that patient?
Dhiren Patel, PharmD: There are a few things, right off the bat, where there’s not a lot of controversy and where we can definitely help our patients with cardiovascular disease management. One is with antiplatelet therapy, right? If they meet the age requirements—50 years of age. Secondary prevention—the data are pretty robust. Primary prevention—you have to have that conversation and make that risk-benefit consideration. For those patients who can’t tolerate aspirin therapy, there’s additional considerations, such as Plavix. When we look at blood pressure control, I think everyone recognizes the importance of that, and of some of those long-term implications there. Now, there are a lot of different medications that you could choose, but the message there is to make sure that you’re controlling the patient, especially a patient with type 2 diabetes. You have an ACE or an ARB on board, at least for one of your 2 drugs that you might have if you’re doing combination therapy for renal protective, and those reasons.
Then, the last one is from a cholesterol standpoint. We know that statins have kind of been the mainstay of therapy. That’s, again, generically available. It is something that you can do, to help move that needle. And, most recently, we’ve seen PCSK9 inhibitors that are starting to demonstrate some additional cardiovascular risk reduction. And so, we have a good idea of what to do there. You could argue that the PCSK9 inhibitors are still a little bit confusing. But, if you take those out, the rest of it hasn’t changed a whole lot, in terms of, “These are the medications. These are the goals.” We can certainly make an impact on those patients. So, I would definitely say to start there. Introduce residual cardiovascular risk. Despite doing all of these things, these patients are still at a higher risk. That’s when you want to bring on these additional agents, such as the new diabetes medications, where I can still produce an additional cardiovascular risk reduction in patients who are adequately maintained, from a blood pressure standpoint, antiplatelet standpoint, and a statin standpoint.
Troy Trygstad, PharmD, MBA, PhD: We also have to remind ourselves that every patient who walks into that exam room has a different set of genes.
Dhiren Patel, PharmD: Absolutely.
Troy Trygstad, PharmD, MBA, PhD: So, we know that individualized care is really important.