Defining and Obtaining Optimal Glycemic Control

An overview regarding the ADA and AACE guidelines and steps needed to ensure that patients obtain optimal glycemic control.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Optimal glycemic control depends on which guidelines you’re looking at. And so the 2 major bodies that we have are the ADA [American Diabetes Association] guidelines as well as the AACE [American Association of Clinical Endocrinologists] guidelines, and they favor more strict glycemic control, and so they’re favoring an A1C [glycated hemoglobin] of less than 6.5 if you can reach there safely. Whereas the ADA guidelines are favoring a goal of less than 7, also bear in mind that you need to be able to get a patient there without any harm to just hypoglycemia. And so they do differ a little bit, but what they do agree on is kind of the approach and kind of the medications that should be used to get folks to goal. Both guidelines recommend metformin as their first-line option when controlling or looking to control blood sugars.

Pharmacists are in a key position to be able to kind of emphasize what needs to be done from a glycemic standpoint from a variety of ways. So if you think about those folks who are most easily accessible, it’s usually your folks who are on the frontlines in the community pharmacy. They have an idea of the different prescriptions that they’re getting filled, a good idea of the different providers that are in and around that pharmacy. And so if patients are looking to get a referral to an endocrinologist, a podiatrist, an optometrist, usually having those relationships puts them in a unique position to be able to kind of connect some of the dots, in terms of not only the referral of care but also when you think about having all the different specialists and getting all the medications filled in 1 spot, from a drug interaction standpoint to knowing what medications are working, what medications are not working, why they’re stopping certain medications, why they may not be coming back in the second month, the third month to get their medications refilled.

And so those are all places of entry or areas where a pharmacist could intervene and have that discussion with that patient to dig a little bit deeper. Is it the adverse effect of the medications? Are you unhappy with your treatment? Are you unhappy with your provider? What are things that I can do to kind of make this process a little bit easier? When we think about drug therapy, that voice and that second time that the patients typically hear it, maybe they’ve heard it a little bit or a quick version of it at their doctor’s office. They hear it again from someone whom they’ve had an ongoing relationship with, whom they see a lot more often. That usually helps. And again, being able to hear from someone they have more established relationship with typically also helps.

The way that I work with clinicians to help them achieve glycemic goal for their patients is—we work in a multidisciplinary clinic. And so my role as a clinical pharmacist and that of a certified diabetes educator is to work alongside a group of providers. And so I have 3 endocrinologists who I work with and a nurse practitioner. And we take referrals from our primary care colleagues for those challenging patients who have more complex needs. They need some of the newer agents that are out there for type 2 diabetes. We get a bulk of those referrals. And from that point onward, we kind of take over the care, and we’re managing and comanaging them along with their primary care physicians. But we’ll make sure they get on the right medications. If there are certain medications that need to be taken off or certain ones that just might be restricted to being used by the endocrine service, those are the ones that we would kind of put on, making sure that that patient is still being comanaged, but we’ve kind of taken the lead in managing that specific condition.

Tripp Logan, PharmD: When we receive patients, whether that’s referral or walking into our pharmacies, who have high blood glucose, who have diabetes, who have prescriptions for diabetes medications, our No 1 goal is to ensure that they have access to the medication and the treatment that they need. That’s the first thing. Nothing can improve if they don’t have access to the care that they need. Sometimes it’s out-of-pocket issues. A lot of times it’s health literacy—they just don’t understand that they need to access these things. We have our pharmacies in rural Missouri and the Mississippi River Delta, and our area is somewhat of a healthy-food desert. So having access just of the foods that are really important to them is something. And so when they’re coming in and we’re talking through these things, access is the first most important thing.

And then if we ensure that they have access to the medication that they need, the second step is always to make sure that they understand why they need this. Health literacy—we have a lot of patients who don’t read very well, don’t understand, misunderstand how these things work. Once we ensure those 2 things happen, then we get into setting goals: What did your prescriber set as your goal? How can we work with that prescriber to ensure that we meet those goals?

And then we work to ensure that we have follow-up with the patient. The more we communicate back and forth with their prescriber, primary care providers, any other referrals that we work with, whether that’s through dietitians or other social. We’ve got community health workers on staff at our staff that we refer our diabetes patients to help them along on their journey. All this information we communicate back with the prescriber.

So if, for instance, access is an issue because of cost, I looked before this session and we did almost 500 prescriptions for GLP-1s [glucagon-like peptide-1 agonists] last year. Well, in those we had some patients with co-pays as high $600 and some co-pays as $0. Access is an issue, out-of-pocket is a concern. So once we ensure that out-of-pocket is OK, say you have a patient for whom $600 is too much, we contact the prescriber and explain the situation; work through the formulary with the prescriber as a team, and find that prescription that fits that patient’s budget best. And then we move on with that as our primary treatment option in that situation.

Prescriber communication is super important. It’s not always 100% positively received from the prescriber. Most enjoy having another member of the team who’s helping their patient through this journey and following them along the way to ensure that they’re moving toward not only that goal of keeping their blood sugar under control but also that positive-outcome goal when you look at that cardiovascular disease and all these other adverse things that can happen with diabetes.