Unanswered Questions in Diabetes


Troy Trygstad, PharmD, MBA, PhD; Javier Morales, MD, FACP, FACE; Dhiren Patel, PharmD; and Tripp Logan, PharmD, highlight unanswered questions in managing diabetes including the role of inflammatory markers, possible synergistic effects of diabetes drugs, and the use of community pharmacists to help monitor therapy.

Troy Trygstad, PharmD, MBA, PhD: Switching topics a little bit, what don’t we know? What questions are still unanswered about cardiovascular risk reduction? We have folks who focus on cardiology. We have folks who focus on diabetes. There is still a lot to be learned about risk reduction. But, what about this conjoint diabetes/cardiovascular circumstance? What still remains out there, as far as unanswered questions? It just seems like we’re learning more and more, the less we silo out patients, health care professionals, and disease states.

Javier Morales, MD, FACP, FACE: I think we’ve already established that if we look at collaborative benefits—controlling your hemoglobin A1C, blood pressure, and cholesterol—once you hit this composite endpoint, then it winds up being beneficial in terms of cardiovascular outcomes. One of the questions that remains unanswered, and there is some research that’s looking into it, is going to be the inflammatory markers and whether or not these drugs that offer significant cardiovascular benefit do so by altering cardiovascular markers to some degree or another.

Troy Trygstad, PharmD, MBA, PhD: And that seems to be a trend over time—this issue of inflammation, generally. Across all sorts of pathologies, we’re learning that inflammation plays this critical role. This makes sense because it’s a natural response to the body saying, “Hey, something is wrong here.” But that generalized inflammation is not good, right?

Dhiren Patel, PharmD: I definitely agree with that. Where I think we could have some additional information that would help is when we’re looking at it from a comparative efficacy standpoint. Right now, we know from these trials, “This drug did it in this trial.” And, “This drug did it in this trial.” But, what about the real world? If I’m using a GLP-1 and a SGLT2 inhibitor, or maybe in the setting of a PCSK9 inhibitor, am I going to get synergistic cardiovascular risk reduction? I don’t know. I know that some of the mechanisms are different, of how they’re producing the cardiovascular benefit. That type of information would be really, really helpful.

Javier Morales, MD, FACP, FACE: Additive benefit. Well, I don’t know. That’s a good question, and only time will tell. I’m sure that plenty of data will be available, in the years to come—retrospective meta-analysis data.

Troy Trygstad, PharmD, MBA, PhD: So, it’s always evolving. It’s certainly not uncomplex, if you will. Dr. Morales, if you had pharmacists available to you—a pharmacist or maybe even a pharmacist in a clinic, and pharmacies in the community that provide extra support—what’s the wish list look like for you? What’s the, “I would love to have this, this, and this,” that would be impactful for the patient and practice fulfillment, or reduced stress, or time saving, or enjoyment?

Dhiren Patel, PharmD:Burnout.

Troy Trygstad, PharmD, MBA, PhD: We know that’s an issue, particularly with primary care. I think the pharmacist community is very interested in what that wish list is. I suspect that folks like Dhiren and Tripp look at that and say, “Great. If that’s 1, 2, and 3, I’ll do 1, 2, and 3.” What is it?

Javier Morales, MD, FACP, FACE:

I think it has to do with safety, efficacy, and achieving targets. The pharmacist could be extremely instrumental, with that regard, for several reasons. In my opinion, it’s likely related to things like avoiding polypharmacy, which is very common. We have so many different agents that are available, that are prescribed for this, that, and the other. And, “Will this drug interact adversely with that one?” So, now it becomes a safety issue. Now, there is the efficacy part of, “Well, maybe a recommendation of making a substitution of one agent for another might enable an easier achievement of target?” And then, the third thing that would be very useful is the pharmacist’s role in ensuring adherence.

Troy Trygstad, PharmD, MBA, PhD: Or coaching, generally.

Javier Morales, MD, FACP, FACE: Yes.

Troy Trygstad, PharmD, MBA, PhD: There’s fill rates, and then there’s optimal administration, optimal regimen, and follow up. Tripp, the community pharmacy is in a wonderful position for follow up. How do you convince the physician and extender provider community in Charleston and the surrounding areas that, “Hey, I’m in community pharmacy. I have access to this patient far more often.” Particularly, at Community Care, we found that complex patients go to their pharmacy 35 times a year. And, they go to primary care 3.5 times a year. What is that value proposition? How do you make that pitch to those physicians in your community? “Hey, I’m in front of patients all the time. I can help you monitor these patients or trigger action.” What does that pitch look like?

Tripp Logan, PharmD: It’s similar to what you just said. The values are the touch points and the ability to monitor and keep track of that patient beyond the office visit. And, to have a feedback mechanism in the field, even with touch points within the home. That’s really important to relay, and this is something that I talk to our pharmacists, students, and residents about when we go and engage practices and do services. We’ve all got this list, in our back pocket, of the stuff that we do. We want to tell them about everything we do, and all of the stuff that we can do. But, what we need to do is ask, “What do you need?” We hope that something on that list is actually applicable to what the need is. And so, I think that’s most valuable. “Where are your pressure points? We can help with a lot of stuff. We see a lot of patients. We’re here to help. What’s your biggest pressure point?” To me, that’s been the most successful method.

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