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Help complex diabetes patients reach their goals by individualizing treatment

Background:

  • Nearly 30 million people have diabetes and more than 85 million have prediabetes, but many are unaware of their condition.
  • Early intervention to lower blood glucose levels offers lasting benefits in reducing complications.
  • Pharmacies can offer numerous products and services to help patients with diabetes, including screening, vaccines, resistance bands and footwear.
  • In addition to diabetes education, pharmacists can help patients reach their goals through med sync and Medication Therapy Management (MTM).

For patients with diabetes, lowering their A1C levels provides lasting benefits. Pharmacies can help them do that with individualized coaching. Helping patients control their blood glucose levels reduces complications including eye, kidney and nerve disease. Controlling glucose can reduce the long-term risk of stroke and coronary artery disease.1 For example, a 1% decrease in A1C levels can reduce microvascular complications by 35%.

Less than 60% of patients take advantage of diabetes self-management education (DSME), although most types of insurance cover it when providers meet their standards. One study found just 6.8% of privately insured patients take a diabetes class.2 Encourage your patients to speak with an insurance representative to see if a diabetes education course is covered under their plan. Medicare Part B will cover 10 hours of initial training and two hours of follow-up training each year, and most states require private insurers to cover diabetes education, but Medicaid coverage is less widespread.3

Even if your pharmacy doesn’t have a formal diabetes education program, through Medication Therapy Management (MTM), medication synchronization and other efforts you can help diabetes patients better understand their disease and reach their goals.

The bottom line: Catch diabetes early and treat it aggressively

“Pharmacists can have positive influences on patients’ lives,” said Marjie Laciak, pharmacist at Fagen Pharmacy in Valparaiso, Indiana. “Even if you don’t have a diabetes education program, pharmacists can be very helpful.”

Example: A 63-year-old patient diagnosed with diabetes had an A1C level of 12.6. After six weeks of intervention involving metformin and dietary changes, his A1C was down to 7.4. Laciak called this one of the most dramatic A1C reductions she has seen.

She offers these recommendations:

  1. Encourage early screening. Of the 29.1 million people with diabetes, 1 in 4 don’t know they have the disease.4 Of the 86 million people with prediabetes, 90% don’t realize they have it. If in the prediabetes state, they may be able to bring their blood glucose levels under control with lifestyle, diet and medication.
  2. Individualize A1C goals. Although American Diabetes Association (ADA) guidelines recommend an A1C level of 7 or less for most people, setting realistic goals requires taking into account multiple factors, including the patient’s motivation, risks for hypoglycemia and other complications. In choosing recommendations for medications, multiple factors also come into play, including efficacy, cost and potential side effects.
  3. Discuss lifestyle changes. Talk with patients about their optimal weight. Keeping a daily food and activity diary can help them track their progress. Explain a new recommendation from the ADA about not sitting for more than 90 minutes, and encourage them to get 150 minutes of activity a week.
  4. Recommend resources. Be ready to recommend other resources, such as a senior center with activities where they may feel more comfortable exercising than a gym, a place where they can have a sleep study performed, and a behavioral health team if they may feel depressed. Since smoking increases the risk of diabetes by 30%, offer customers smoking cessation counseling and support or refer as needed. Offer recommendations for how they can break the triggers for their smoking and develop heathy habits.
  5. Offer A1C testing. Laciak’s pharmacy offers A1C testing for $25 to $30. It takes five minutes for results, and patients don’t need to fast in advance. When patients’ therapy changes or they aren’t meeting goals, their A1C should be tested quarterly, but many patients may see their doctor only once every six months — making in-pharmacy testing a perfect option.
  6. Check vaccinations. Check that a patient’s immunizations are up to date, including the pneumonia, shingles and hepatitis B vaccines.
  7. Watch for depression. Depression is also a complication with diabetes. Ask these two simple questions to signal whether to refer patients to their primary providers or a mental health professional: “Over the last two weeks, have you felt down, depressed or hopeless?” and “Over the last two weeks, have you felt little pleasure in doing things?”
  8. Improve testing. Often patients test their blood at the same time every day, which doesn’t give a complete picture of their glucose control. Over a month, Laciak recommends testing at a different time each week: morning, two hours after lunch, right before dinner, and at bedtime. That gives a more complete picture without the patient paying for extra test strips.
  9. Follow up in your workflow. MTM and med sync both offer time to talk with patients regularly about their diabetes. “Med sync triggers them to come in and see me every month, even if only for five minutes,” Laciak said. With med sync, for example, it’s easy for a pharmacist to recognize if a patient isn’t using a medication. The pharmacist can discover what the problem is and help to resolve it. During a comprehensive medication review (CMR), pharmacists can identify, resolve and prevent medication-related problems, including untreated conditions, improper drug selection and adverse drug reactions.

ABCs and 4 Ms

“As pharmacists we can easily get overwhelmed with diabetes,” Laciak said. “There’s so much to look at and so much that we can’t do for the patient that we dismiss helping them. We should focus on ‘the ABCs,’” meaning monitoring A1C, blood pressure and cholesterol.

Laciak also suggests reviewing “four Ms” of diabetes self-management with patients when they pick up their prescriptions each month:

  • Medication. Discuss any issues with adherence or side effects.
  • Monitoring. Review the patient’s blood sugar log to identify patterns. Talk about figures being “above target” or “below target,” instead of saying, for example, that their blood sugar is “high.”
  • Meals. Review the patient’s food diary and discuss any changes needed in calories or carbohydrates.
  • Movement. Recognize the patient’s efforts to increase physical activity.

When pharmacists take time to work with patients on their diabetes, Laciak said, “They know that we care. They know you have a level of expertise they can’t find just anywhere.”

Diabetes education isn’t about lecturing a patient but is about helping them self-manage. Know your patients’ goals and be ready with recommendations to help them reach those targets.

Resources
“Managing the Complicated Diabetes Patient,” a webinar with Marjie Laciak, pharmacist at Fagen Pharmacy in Valparaiso, Indiana, is available through Health Mart UniversitySM.

She also recommends:

  • The Treatment Algorithm from ADA and European Association for the Study of Diabetes, which includes recommendations for medications at various stages.
  • A BMI chart for discussing a patient’s optimal weight, including the recommended calories and grams of fat per day.
  • Joslin Diabetes Center’s booklet, “Diabetes and Sleep Problems.”
  • A blood glucose calculator, to show patients the impact even a 0.5% difference in A1C can make.
  • The Patient Health Questionnaire (PHQ-9) to help determine whether a patient should be referred for mental healthcare because of depression.

 

 

1 “The UK Prospective Diabetes Study: Clinical and Therapeutic Implications for Type 2 Diabetes,” Paromit King, Ian Peacock, and Richard Donnelly, British Journal of Clinical Pharmacology, November 1999. LINK
2 “New funding mechanisms offer opportunity to improve access to diabetes education,” David Weingard, Manage Healthcare Executive, Dec. 5, 2016. LINK
3 “Reconsidering Cost-Sharing for Diabetes Self-Management Education,” Harvard Law School Center for Health Law and Policy Innovation, June 2015. LINK
4 “A Snapshot: Diabetes in the United States,” Centers for Disease Control and Prevention. LINK

 

Note: The information provided here is for reference use only and does not constitute the rendering of legal or other professional advice by McKesson. Readers should consult appropriate professionals for advice and assistance prior to making important decisions regarding their business. McKesson is not advocating any particular program or approach herein. McKesson is not responsible for, nor will it bear any liability for, the content provided herein.