Expert Discusses Role of Pharmacist in Managing Patients with T2D

In an interview with Pharmacy Times® at the American Society of Health-System Pharmacists Summer Meetings and Exhibition, Katherine Harte, PharmD, a PGY2 ambulatory care pharmacy resident at the Rhode Island Hospital in Providence, Rhode Island, discusses the impact of pharmacist management on SGLT2 inhibitors and GLP-1 receptor agonist utilization in patients with type 2 diabetes mellitus.

She addresses the role of pharmacists in managing patients on these treatment regimens and how pharmacists can help manage  any adverse effects caused by these drugs.

Q: How have SGLT2 inhibitors and GLP-1 receptor agonists changed the treatment paradigm for patients with diabetes?

Katherine Harte: The treatment paradigm for patients with Type 2 Diabetes (T2D) has really changed within the past few years in regard to the use of SGLT2 inhibitors and GLP-1 receptor agonists. Even just a few years ago, they were mainly recommended for patients who weren't at goal A1C after being started on Metformin. However, the most current 2022 guidelines do recommend the use of SGLT2 inhibitors and GLP-1 receptor agonists in patients with certain comorbidities regardless of their target hemoglobin A1C, what their current level or baseline level was, or their Metformin use. There's definitely been large changes in the treatment paradigm, and the most important thing is actually implementing these into practice, and that's a place that pharmacists can definitely play a large role.

Q: What are the considerations for medication selection among these patients?

Katherine Harte: So that's another great question. There's a lot of different considerations for choosing which agent to utilize, and probably the most relevant is looking at the comorbidities that the patient has. The 3 that I think of mainly would be heart failure, chronic kidney disease (CKD), and ASCVD.

In terms of heart failure, typically what we reach for is one of the SGLT2 inhibitors, primarily empagliflozin, or dapagliflozin. Since they do have indications for both heart failure and T2D.

For CKD, again, SGLT2 inhibitors are used preferentially but can consider the use of GLP-1 receptor agonist as well.

Then lastly, for patients who have ASCVD, both SGLT2 inhibitors and GLP-1 receptor agonists can be utilized, but you want to be focusing on the ones that have the most data behind them. So those would be empagliflozin, canagliflozin, and then in terms of the GLP-1 receptor agonist, those would be dulaglutide, liraglutide, and subcutaneous semaglutide.

I think that kind of summarizes some of the most important things, but as always, it's important to consider contraindications for the medications or renal dosing cutoffs, for example, and then making sure to integrate all of those into practice. Relating to us as pharmacists, if we have a collaborative practice agreement, making sure that all of these considerations are made into that collaborative practice agreement, and I know that is the case at my institution.

Q: What is the role of pharmacists in managing patients on these treatment regimens for diabetes?

Katherine Harte: That is a really important question because I think we as pharmacists have a very important role in the management of these medications. One that comes to mind is, in terms of affordability, because these medications are all still brand name only, they can be very expensive with large copays, depending on a patient's insurance status.

We, as pharmacists, can really help our patients through the prior authorization process, through helping them apply for manufacturer assistance programs or various other ways that we can assist them.

Another way that we can help is trying to prevent clinical inertia and really promote the use of these medications and optimize their dosing and make sure that patients are on guideline directed medical therapy for diabetes. This actually really relates well to my research project that I'm presenting here at the conference because the results actually indicated that pharmacists being involved in patients care within a primary care clinic significantly increased utilization of both GLP-1 receptor agonists and SGLT2 inhibitors. I think that just shows how important it is to have pharmacists involved in the care of these patients.

Q: How can pharmacists help manage any adverse effects caused by these drugs?

Katherine Harte: I think that's a great question to go with the question beforehand, because yes, we're interested in getting the patients started on these medications, but you want to make sure that they can continue on the medications. I would say one thing that we can do is making sure to help them manage those side effects or adverse effects, so giving them some ideas in terms of SGLT2 inhibitors. They commonly cause increased urination so having some ideas to maybe limit intake of carbohydrates or just making sure to take the medication in the morning to avoid nocturia.

On the other hand, we have the GLP-1 receptor agonist they classically have GI adverse effects and some ideas there to help manage that is to try to avoid fatty or fried foods, and as well as tried to eat smaller meals throughout the day.

Another place that pharmacists can play a role is actually in the selection of the medications. So going back to the GLP-1 receptor agonist, if somebody is on a shorter acting agent, then actually switching them over to a longer acting agent is a recommendation that we often make because the longer acting agents have less GI adverse effects. That just summarizes some of the areas that pharmacists can help managing these adverse effects, so not only are we helping to increase the utilization of them, but we're helping patients stay on these guidelines directed medical therapy.