OTC Cases: February 2022

CASE 1: Cinnamon

Q. SD is a 51-year-old woman who calls seeking advice. She was diagnosed with type 2 diabetes 2 years ago and had been taking metformin to keep her HbA1c level at the goal up until a few months ago. SD’s physician told her that her HbA1c level had increased, and it was time for her to add another antidiabetic medication. SD asked the physician for time to think about it and to implement the recommended lifestyle modifications. A friend recommended cinnamon capsules to SD, explaining that cinnamon has been proven to help regulate blood glucose and manage diabetes. Otherwise, SD is healthy and does not take any other medications. What information should the pharmacist provide to SD regarding taking cinnamon capsules for diabetes?

A. Cinnamon has been used as a dietary supplement to regulate glucose in type 2 diabetes for several years. Study results from 2003 through 2007 show a significant impact of cinnamon supplementation on HbA1c, lipid, and serum glucose levels. The most studied dose was 2 g daily. Cinnamon 2000-mg capsules are available OTC. The theoretical explanation of the benefits is that cinnamon increases insulin sensitivity and intracellular movement of glucose. More recently, meta-analyses were conducted to assess the impact of cinnamon on diabetes. The meta-analyses results show conflicting data regarding taking cinnamon for diabetes. The results of 1 meta-analysis of 10 trials showed no impact of cinnamon on HbA1c or serum glucose levels, whereas the results of another meta-analysis of 8 trials show a significant impact of cinnamon on serum glucose in type 2 diabetes. Given that the data are inconclusive, pharmacists should not recommend cinnamon use for diabetes treatment.^1-3

CASE 2: Chromium

Q. SD was impressed with the information the pharmacist provided regarding cinnamon as a dietary supplement for diabetes. To follow up, she asks about chromium supplementation for diabetes. What information should the pharmacist provide regarding chromium supplementation for diabetes?

A. Chromium is an essential mineral that is present in foods
in small amounts. The theoretical explanation of the mechanism of benefits is that chromium may improve glucose tolerance by decreasing insulin resistance. Chromium picolinate is available OTC in doses ranging from 200 to 1000 μg. Studies have investigated the impact of chromium on glucose control. Although some study results show chromium plays a role in reducing blood glucose levels and improving tolerance, others show chromium has no impact. Dietary supplementation with chromium picolinate has not consistently demonstrated benefit in glucose control for type 2 diabetes. Therefore, it is not listed in diabetes guidelines.^4-5

CASE 3: Glucose Monitoring

Q. DP is an 84-year-old man with type 2 diabetes who recently had blood work done. DP was informed that his glycated hemoglobin (HbA1c) level was 14%, indicating that his diabetes is not well controlled. His physician asked DP whether he tests his blood glucose levels at home. In addition, the physician planned to initiate a long-acting insulin and would like to titrate the dose up as needed per the fasting blood glucose results. DP would need to provide blood glucose data from home to achieve this. DP had been reluctant to check his glucose levels at home because of the painful fingerstick and dexterity requirements of a traditional glucometer. He is seeking information about the FreeStyle Libre 2 continuous glucose monitoring (CGM) device. What information can the pharmacist provide?

A. As opposed to a monitor that measures glucose in the blood via a fingerstick, FreeStyle Libre 2 measures the glucose in the patient’s interstitial fluid, which lies below the skin but above the blood vessel layer. Following the ingestion of carbohydrates in meals and snacks, glucose first enters the blood stream in vessels and is then absorbed into the interstitial fluid. As such, a glucose reading from the FreeStyle Libre 2 CGM is slightly delayed compared with blood glucose readings via a fingerstick. To overcome this barrier, the CGM has a trend indicator on the reader that shows whether the glucose is trending up, down, or staying consistent to predict outcomes.^6,7

If DP were to obtain a prescription for FreeStyle Libre 2, the supplies provided would be a reader and sensors. The sensors would be applied to the back of his arm and are approximately the size of a quarter. Sensors include a microfilament that lays in the interstitial fluid to continuously track glucose. The sensor should be changed every 14 days. To allow for remote monitoring, DP would create an account where he can agree to share the CGM data with his physician’s office so insulin changes can be made accordingly.^6,7

The data and scanning can be completed on the reader or via a smartphone application that is available for both Android and iOS devices.^6,7

CASE 4: Hypoglycemia

Q. RJ is a 66-year-old man with type 2 diabetes who is seeking advice. He takes insulin glargine and metformin for his diabetes. RJ’s physician recently prescribed Admelog for mealtime injection. RJ has been injecting his 4-unit dose approximately half an hour prior to each meal, but he has been experiencing an inability to concentrate, lightheadedness, and sweating. His friend who has diabetes mentioned that RJ may be experiencing hypoglycemia. What advice should the pharmacist give?

A. The insulin regimen RJ described includes both long- and rapid-acting insulins. When administered correctly with relation to meals and with consistent diet, rapid-acting insulin is less likely to cause hypoglycemia. RJ is injecting his Admelog too early in relation to his meals. The correct time to inject the Admelog would be within 15 minutes of meals. One strategy is to inject the dose while sitting down to eat, immediately before the first bite of food. This ensures the medication has not started to reduce blood glucose levels before a patient has ingested food.^8,9

For symptomatic hypoglycemia that he described, instruct him to check his blood glucose and eat 15 g of simple carbohydrates if the glucose reading is less than 70 mg/dL. Examples of simple carbohydrates that may be found at home include 8 oz of milk, 4 oz of orange juice or regular soda, 5 to 6 Life Savers candies, or 1 tbsp of honey or sugar. After 15 minutes, the patient should check the blood glucose reading again to ensure it has risen to above 70 mg/dL. If not, he should repeat eating 15 g of simple carbohydrates. Once blood glucose rises to 70 mg/dL, instruct patients to eat a small snack and inform a medical provider in case changes to the diabetes regimen are needed.^9,10

Rupal Patel Mansukhani, PharmD, FAPhA, NCTTP, is a clinical associate professor at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, in Piscataway, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

Ammie J. Patel, PharmD, BCACP, BCPS, is a clinical assistant professor of pharmacy practice and administration at Ernest Mario School of Pharmacy
at Rutgers, The State University of New Jersey, in Piscataway, and an ambulatory care specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.

References

1. Khan A, Safdar M, Ali Khan MM, KhattakKN, Anderson RA. Cinnamon improves glucose and lipids of people with type 2 diabetes. Diabetes Care.2003;26(12):3215-3218. doi:10.2337/diacare.26.12.3215

2. Leach MJ, Kumar S. Cinnamon for diabetes mellitus. Cochrane Database Syst Rev.2012;2012(9):CD007170. doi:10.1002/14651858.CD007170.pub2

3. Davis PA, Yokoyama W. Cinnamon intake lowers fasting blood glucose: meta-analysis. J Med Food.2011;14(9):884-889. doi:10.1089/jmf.2010.0180

4. Anderson RA, Polansky MM, Bryden NA, Canary JJ. Supplemental-chromiumeffects on glucose, insulin, glucagon, and urinary chromium losses in subjects consuming controlled low-chromium diets. Am J Clin Nutr.1991;54(5):909-916. doi:10.1093/ajcn/54.5.909

5. Balk EM, Tatsioni A, Lichtenstein AH, Lau J, Pittas AG. Effect of chromium supplementation on glucose metabolism and lipids: a systematic review of randomized controlled trials. Diabetes Care.2007;30(8):2154-2163. doi:10.2337/dc06-0996

6. Haak T, Hanaire H, Ajjan R, Hermanns N, Riveline JP, RaymanG. Flash glucose-sensing technology as a replacement for blood glucose monitoring for the management of insulin-treated type 2 diabetes: a multicentre, open-label randomised controlled trial. Diabetes Ther.2017;8(1):55-73.doi:10.1007/s13300-016-0223-6

7. Unger J, Kushner P, Anderson JE. Practical guidance for using the FreeStyle Libre flash continuous glucose monitoring in primary care. Postgrad Med. 2020;132(4):305-313. doi:10.1080/00325481.2020.1744393

8. Donnelly LA, Morris AD, Frier BM, et al. Frequency and predictors of hypoglycaemia in type 1 and insulin-treated type 2 diabetes: a population-based study. Diabet Med.2005;22(6):749-755. doi:10.1111/j.1464-5491.2005.01501.x

9. Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabetes. Diabetes Care.2003;26(6):1902-1912. doi:10.2337/diacare.26.6.1902

10. Carlson JN, Schunder-Tatzber S, Neilson CJ, Hood N. Dietary sugars versus glucose tablets for first-aid treatment of symptomatic hypoglycaemiain awake patients with diabetes: a systematic review and meta-analysis. Emerg Med J.2017;34(2):100-106. doi:10.1136/emermed-2015-205637