25 Sweetening the deal: improving health outcomes for patients with diabetes mellitus

Edward M. Saito, PharmD, BCACP

John Begert, PharmD, BCACP

Brandon Nuziale, PharmD, BCACP

Vivian Chau, PharmD

Miranda Steinkopf, PharmD

Introduction

Diabetes mellitus (DM) is a chronic metabolic condition that impacts blood glucose levels in the body. According to the Centers for Disease Control and Prevention (CDC), type 2 DM encompasses approximately 90-95% of individuals who are diagnosed, while the remaining 5-10% of persons have type 1 DM. Type 2 DM is the result of a defect in insulin action, also known as insulin sensitivity, while Type 1 DM is an autoimmune reaction which stops the body from producing sufficient insulin. Other forms of DM include gestational diabetes, which develops during pregnancy, and prediabetes, which is an abnormal blood sugar level that has not yet reached the point of a full DM diagnosis.^1-2

In the United States, approximately 34.2 million adults have DM, which is the seventh leading cause of death in the US and the leading cause of kidney failure, lower-limb amputations, and adult blindness. It is also a significant contributor to the development of atherosclerotic cardiovascular disease. Populations at highest risk for developing DM includes those who are overweight, over 45 years of age, have a family history of DM, and/or are in one of the following populations: African American, Hispanic/Latino, American Indian, Alaskan Native, Pacific Islander or Asian American. Collectively, racial/ethnic minorities account for approximately 23% of the US population at risk for prediabetes and type 2 DM.¹ Organizations such as the CDC and American Diabetes Association (ADA) have developed numerous strategies to treat and prevent DM, which encompasses lifestyle modifications, dietary changes, and pharmacological interventions.^1-3 As pharmacists, it is important to consider a holistic view of the patient, considering not only medications, but lifestyle factors and other social determinants of health that may affect disease management.

The ADA recommends incorporation of care management teams, including various providers, such as pharmacists, nurses, and dieticians, as a strategy to improve the outcomes related to DM.³ Due to extensive medication and disease knowledge, pharmacists are well positioned to participate in management of DM. Involvement of pharmacists across settings, including community pharmacies, primary care clinics, and hospitals has shown positive outcomes related to HgbA1c, blood pressure, low-density lipoprotein (LDL), triglycerides, and body mass index (BMI).⁴ Racial/ethnic minorities appear to also benefit from pharmacist management of DM, with evidence of improved outcomes and patient perceived support regarding medication education and management, non-medication related education, social support, and care coordination.^5-6 Collaborative practice agreements, through which a licensed provider refers a patient to a pharmacist under a protocol allowing the pharmacist to perform specific patient care functions, are one way in which pharmacists can become directly involved in DM management to help improve the health of individual patients and larger communities.

Case (part 1)

CC: “I need to refill my prescriptions.”

Patient: PN is a 48-year-old Vietnamese male (66 in, 75.5 kg).

HPI: Through the assistance of an interpreter service, PN speaks with your pharmacy technician regarding his refills. However, he does not bring the prescription bottles and does not know which medications he needs to have refilled. The technician asks you to review the patient’s medication profile.

PMH: T2DM (x 8 years)

FH: Unknown

SH: Unknown

Medications:

• Metformin 1000 mg one tablet twice daily (#60 last refill one month ago)
• Glipizide 10 mg twice daily (#60, last refill four months ago)
  • Patient reports that he stopped taking it a few months ago because it made him feel “low” while he was at work, and he was afraid of being fired from his job
• Sitagliptin 100 mg once daily (#90, last refill 45 days ago)
• Rosuvastatin 10 mg daily (#90, last refill one month ago)

Allergies: NKDA

SDH: The patient moved with his family to the US from Vietnam approximately nine years ago. He does not drive and relies on public transportation to get to the pharmacy. He has Medicaid insurance with $0 copays for covered medications on a limited drug formulary.

Case Questions (part 1)

1. What questions can the pharmacist ask PN to identify the factors contributing to their nonadherence?

2. What causes might be contributing to PN’s reported/unconfirmed hypoglycemia?

3. What types of resources can community pharmacists provide or connect patients to improve health outcomes associated with DM?

Case (part 2)

CC: “I know I should be taking better care of myself to improve my blood sugar control, but I am so busy and constantly worried about my family and their wellbeing that I don’t have time for myself.”

Patient: PN presents to your family medicine clinic for an initial comprehensive medication management visit after medication non-adherence was identified by the community pharmacist. His wife accompanies him today and helps to translate.

FH:

• Mother: alive; T2DM
• Father: alive; HTN
• Maternal grandfather: deceased; T2DM
• Four children; two live in Vietnam, two live with him

SH:

• Tobacco smoker x 30 years
• Drinks alcohol socially

ROS: (+) polyuria, polydipsia, numbness in fingers

Surgical history: None

Vitals:

• BP 130/78 mmHg
• HR 90 bpm

Labs:

Lab	1 month ago	3 months ago	9 months ago	Normal range
HgbA1c	12.1%	10.6%	13.0%	4.2-6.5%
TSH		2.16 IU/mL		0.34-5.60 IU/mL
Na	138 mEq/L		130 mEq/L	136-145 mEq/L
K	4.4 mEq/L		4.1 mEq/L	3.4-5.0 mEq/L
SCr	1.2 mg/dL		0.8 mg/dL	0.6-1.3 mg/dL
Glu (random)	259 mg/dL		314 mg/dL	70-99 mg/dL
Total chol	153 mg/dL			100-199 mg/dL
TG	361 mg/dL			0-149 mg/dL
HDL	29 mg/dL			50 mg/dL
LDL	52 mg/dL			0-99 mg/dL
Alb:Cr	>300 mg/g		30-300 mg/g	0-30 mg/g

SDH: The patient speaks only Vietnamese. PN lives in a multigenerational household with his wife, children and two grandchildren. He works two jobs to support everyone, including a day job at a Vietnamese restaurant and an evening job as a janitor at elementary school. He relies on public transportation and takes multiple buses across the city to get to the clinic.

His annual income is at 75% of the federal poverty level, which, based on the size of his household, qualifies him for Medicaid with a limited drug formulary that includes prior authorization requirements for sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 (GLP-1) agonists. In the past, the patient has expressed concern about utilizing injectable medications as he and his family associate this with loss of limb and even death, plus he states that he is fearful of being perceived by his boss as injecting “drugs.” Additionally, he does not want his family members to think that he is no longer capable of providing for their needs. He has a relatively good understanding of his medical diagnosis and the importance of managing it.

PN states that he eats a traditional Vietnamese diet. His breakfast consists of Vietnamese coffee, with white rice with eggs. His lunch is usually rice with some sort of meat (chicken/pork/beef) and various vegetables. His dinner consists of either a noodle or rice dish (like lunch). He drinks a variety of beverages (tea, water, fruit juices, coffee) and eats snacks such as rice cakes and fruits. He says he does not engage in regular physical exercise.

Case Questions (part 2)

4. What social determinants of health may be impacting PN and how might these negatively affect his type 2 DM control?

5. What type of referrals can the ambulatory care pharmacist make that would be beneficial for improving health outcomes for this patient?

6. Considering patient-specific factors, how would you approach lifestyle counseling with PN?

7. Create a medication therapy plan to improve PN’s DM outcomes, including monitoring and follow-up. How would you address the patient’s concerns about injectable therapy?

Author Commentary

The prevalence of DM in Asian adults living in the US is 19.1%.⁷ Asian Americans develop type 2 DM at younger ages and at lower body weights compared to the general population in the US, leading to one in two Asian Americans who have DM not being aware of their diagnosis.⁸ This is important to consider when screening this population for type 2 DM, and once a diagnosis is established, culturally appropriate treatment and counseling is necessary to ensure respectful and effective treatment. Factors that may impact patients’ goals, treatment and blood glucose management include lifestyle, race/ethnicity, and cultural perceptions.⁹ Minoritized racial and ethnic groups, including Asian Americans, should be treated in a way that addresses specific barriers and cultural beliefs and misconceptions.¹⁰ Moreover, prevailing social determinants of health and systemic inequality in access to healthcare services continue to have significant negative consequences on health outcomes for people living with DM.¹¹

DM is a major public health concern, especially among certain racial and ethnic communities, in the US and across the world.¹² As the third-largest group of healthcare professionals in the US, pharmacists must play a role in preventing and improving health outcomes related to DM.¹³ Due to a growing shortage of primary care providers and an increasing number of medication classes approved for use in DM, the accessibility and knowledge of pharmacists is becoming increasingly important to help curb this public health concern.^14-15

Patient Approaches and Opportunities

Pharmacists have a unique opportunity to contribute to the management of DM due to their drug therapy expertise, ability to optimize medications while considering cost effectiveness, and availability for counseling and educating patients on adherence and lifestyle considerations.¹⁶ Addressing patient-specific goals and barriers such as diet, exercise, familial obligations, and treatment options promotes shared-decision making with patients. While pharmacists can make significant contributions to improving DM-related health outcomes, it is important to recognize limitations within this role and be able to effectively utilize available resources to enhance patient care. Furthermore, collaboration among pharmacists working in different settings (e.g., community, ambulatory care, hospital inpatient, long-term care) and between pharmacists and other healthcare professionals will help to address barriers and ensure adequate, equitable treatment for patients in our communities.