GLP-1 Agonists in T2D: Role of the Community Pharmacist

What community pharmacists need to know to ensure best practices surrounding the prescribing and dispensing of GLP-1 agonists for patients with type 2 diabetes.

Troy Trygstad, PharmD, MBA, PhD: So you all are experts in this particular field. You prescribe, and you work closely with endocrinologists and cardiologists and primary care. If I’m a community pharmacist out there, what are the most important things or aspects of GLP-1 [glucagon-like peptide-1] agonists that I need to know, from a product-distribution perspective or from a counseling standpoint or from a progression perspective? What do I need to know if I’m out on that front line in the community?

Susan Cornell, PharmD, CDE, FAPhA, FAADE: The first thing I think they need to know is, is the prescription written correctly? Are the pen needles, if needed, coming with it? The other is storage. Not only do we see this often with GLP-1s, but I see it with insulin, where patients get confused with, where do I store it?

Troy Trygstad, PharmD, MBA, PhD: And it’s not the glove compartment on 100-degree day?

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Oh, of course it is.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: That’s why yours ran out too soon.

Troy Trygstad, PharmD, MBA, PhD: If you can’t leave your son or daughter in the car, don’t leave your GLP-1s.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Right, exactly.

Troy Trygstad, PharmD, MBA, PhD: Your insulins and your other proteins there too. OK.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Yup, but it’s a big thing. I see so many times that patients will put the used product, what they’re using, in the refrigerator. And the unused, for later, is stored above the refrigerator or in a cabinet.

Troy Trygstad, PharmD, MBA, PhD: Like we think of perishable items as food.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Exactly. So again, storage is very important. These do need to be refrigerated and kept in the refrigerator until use. So it’s something as simple as that. And then, also, the pharmacist needs to make sure the patient knows how to use the device correctly. Don’t make the presumption that the doctor, the diabetes educator, the nurse, or even the pharmacist at the clinic did the education. It’s better to hear how.

Troy Trygstad, PharmD, MBA, PhD: Or that they don’t need it more than once.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Exactly. It’s better to hear it 2, 3, 4 times than none. So I think, again, “What were you told regarding how to use this? Using those open-ended questions, make sure that the patient has everything they need to go home and use the medication correctly.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: We talked about how many are in the class, and there are 6 or 7 of them. They all have a different device. I could tell you that we all probably have a formulary that we figured out. You’re like, “This is the only 1 that I can get covered in my area.” So we get comfortable with maybe 1 or 2 devices, or 1 or 2 agents.

You can’t expect everyone to keep up with 6 or 7 of them. But now, because of technology and what we have, it’s easy to pull up a YouTube video. In some of my cases I’ll say, “Let’s watch a video.” Maybe it’s not this demonstration, or you can just write down the link, and they can go home and watch it again if they forget. And so there are different ways you can do it. If you don’t know how to use the newest and latest device, there are a lot of manufacturer videos and resources that you can pull from to kind of augment that. If you have a general gist of the counseling points and a general gist of the instructions, then you can figure out those differences. I hear that a lot from pharmacists, or that there are way too many devices. It’s kind of like what happened with the glucometers. Learn how to use 1 and then just point out the different bells and whistles. Similar things could be adopted and used here.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: You bring up a great point. Most of the companies have a good support system and great patient education tools. I don’t know any company that is not willing to support patient education. Because, again, it goes right back to if the patient doesn’t use it, or use it correctly, the drug is worthless. So even directing them to the patient page on the website or giving them a handout on what to do—again, providing that education to the patient.

Jessica L. Kerr, PharmD: I get this question enough just in my clinic, and I know I went over this with the patient—the missed dosages. I can only imagine how many questions a community pharmacist would end up getting on that. Each of the directions for the missed dosage is different. And so it’s just kind of pulling out, you know, in the package insert if it’s not within the box. You can open it, or whatever, in the community pharmacy or using your resources. But that is 1 thing that really can help a patient. Because typically if it’s within 3 days of when you should have delivered it, you can go ahead and give it. But if it’s more than 3 days, for the majority of the products, then you have to wait until that next time, or you go ahead and decide how you’re going to handle that.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: And I think that the role of the community pharmacist is crucial. Even when we’re not in clinic, if the patient has a question, they’re probably going to have to call their CVS or Walgreens, because I’m not at the VA [Veterans Affairs Boston Healthcare System] every day, for all hours of the day. And I go back to that point [because] maybe it’s good for them to hear it again. You think about whom patients trust. They trust nurses and pharmacists. We’re like number 1 and number 2 And so, a lot of my conversations are like, “Well, I went to my primary care. I went to my doctor, and they gave me this, but I didn’t actually start it. I wanted to talk to you before I did it.”

Troy Trygstad, PharmD, MBA, PhD: Sure. Well oftentimes too, they may be a new patient to your clinic, but they’ve been going to that pharmacy for 40 years.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Correct.

Troy Trygstad, PharmD, MBA, PhD: So there’s still that trust or reinforcement. You know, “Yes, Dr. Patel knows what he’s talking about.”

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: That’s right.

Troy Trygstad, PharmD, MBA, PhD: And “Here’s how we’re going to work together.” But that’s where that trusted relationship exists.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: It’s leverage time. It’s the same set of adverse effects they were told about, and there wasn’t anything different. Or they didn’t minimize something or exaggerate 1. And so I think that helps. But I think them kind of reinforcing it definitely makes a difference.

Troy Trygstad, PharmD, MBA, PhD: So for each of you then, if you could write 1 thing on the prescription besides the prescription that said, “Please do this or that,” what would it be?

Susan Cornell, PharmD, CDE, FAPhA, FAADE: So including…

Troy Trygstad, PharmD, MBA, PhD: I’m handing that prescription to the community pharmacist.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Right. And you have on there the device and the needles.

Troy Trygstad, PharmD, MBA, PhD: The device and the needles.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: But also, I would actually include, “Please review storage.”

Troy Trygstad, PharmD, MBA, PhD: Please review storage is yours.

Jessica L. Kerr, PharmD: I would want a demonstration.

Troy Trygstad, PharmD, MBA, PhD: “Please demonstrate, and if you don’t know, go to this website.”

Jessica L. Kerr, PharmD: Right.

Dhiren Patel, PharmD: I would say just go through the adverse effects and what they can expect.

Troy Trygstad, PharmD, MBA, PhD: OK, and I would put, “Make sure to follow up with our excellent panelists within 1 week.”