Pharmacists Enhance Patient Care Through Medication Titration and Lifestyle Support

Experts Colleen Dawkins, ARNP, RD, a nurse practitioner at Big Sky Medical Wellness, and Maureen Chomko, RD, CDE, a dietitian and diabetes educator at Neighborcaare Health, highlight the expanding role of pharmacists in diabetes management and the importance of a collaborative, multidisciplinary approach to patient care. They discuss how pharmacists can implement standing order protocols for medication titration, regularly check in with patients, and reinforce lifestyle modifications. The conversation also touches on the effectiveness of combining GLP-1 medications with lifestyle interventions, sharing success stories of significant weight loss and improved health markers. They stress the importance of building trust with patients and the benefits of longer appointments to discuss all aspects of a patient's lifestyle.

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Q: How can pharmacists collaborate with dietitians and other health care professionals to provide comprehensive care for diabetes patients?

Maureen Chomko: I think, as I was mentioning, my talk is about having a standard order protocol, and I believe that this is a protocol that pharmacists could adopt if, for example, if there's no dietitian in their organization, or if they're working in a community setting. It is really important to have someone to check in with and if these medicines are under shortage, I know a lot of pharmacies can only give them out one month at a time. So if this patient is coming in every month, there is an opportunity for pharmacists to check in with those patients. If they are embedded within a clinic, such as our pharmacy is, there is an opportunity to have pharmacist work this standing order protocol, which essentially is signed by the medical director, and work with the patient on titrating medications. The newest medication on the market, tirzepatide has a 6 month titration process, and I have just one patient on it because I work with patients with lower incomes, so it's out of affordability for most of my patients, but I have 1 and every month, it's been a fight to get the nephrologist who prescribed it to redo the prescription to titrate it up further, and so I think pharmacists can have a role similarly to dietitians and nurses operating under these standing orders, in which we titrate the meds every month with the patient, and that can also mean we're working with them on their insulin doses if needed, we're titrating those down if needed for either their mealtime or their basal insulin. We're making sure that we're checking in with our patients on side effects, what they're eating, how they're moving their body, just their overall health. It depends on the time, of course that the pharmacist have, but that's again, where we come in the dietitian, if you do have concerns about the patient, if the patient is eating one meal a day or less, if the patient you know is not active, that would be a great referral to connect with a dietitian or a diabetes educator or they're in their primary care clinic or in their community so that we could help again, their entire cardio-metabolic risk with what they're eating, how they're moving, and their blood sugar's etc.

Colleen Dawkins: I agree, and one of the things that comes to mind is that pharmacists are in a great position in many institutions and settings to be a champion for instituting protocols like what Maureen is going to talk about, and having a champion for these types of things we know is going to simplify the process for the prescribing provider is going to increase patient satisfaction, improve patient safety, and improve outcomes overall. So having the pharmacist as a team member is invaluable, and they can do things like reinforcing the lifestyle modifications and things that we talk with them one-on-one about and so even if you're not going into depth, you can just kind of throw out like, "hey, remember when the dietitian talk to you about like protein and moving your body and getting enough sleep and managing your stress? Tell me what your blood sugar's are doing." Those kinds of things. and I agree that there's lots of opportunity for some crossover and support of the pharmacists, the dietician, and the prescribing provider, all in the name of good patient care.

Q: Can you share any patient success stories where integrating GLP-1 agonists with nutrition and lifestyle changes significantly improved their health?

Maureen Chomko: I feel like so many of my patients are on these and they're all doing pretty well. I feel like what I work with is in which patients do I want to integrate the lifestyle changes first, which patients do I want to initiate GLP-! therapy first, I think that is up to the clinician to decide a bit of how can this tool be most successful, and/or do I want this patient to start working on lifestyle tools first, and then we introduced this medication? I think also it's about building some relationship to, I think some patients don't want to take injections and working with a patient for a while and building up trust and them working with you and trusting you that you're not going to prescribe them something scary and being able to introduce this more slowly, as an idea can help also improve outcomes and reduce therapeutic inertia when they have someone that they've been working with for a while recommend the medication like this, show them how to use it, talk to them about it, maybe over 1-2-3 visits, for example, while we're working on other things can be a great success as well.

Colleen Dawkins: I see many patients that have been successful. One that does come to mind recently, we've calculated that she has lost about 65 pounds now and that's 21% of her initial body weight, and her body fat percent is down 5% While her muscle mass is up 4%, which was super fantastic to see, she uses a [continuous glucose monitor], even though she does not have diabetes, and that really helps her to keep focus on what's going on with her blood sugar's based on what she's eating, but she's very consistent with her nutrition and our physical activity, and she's had really great outcomes. So first of all, she was prediabetic before we started the medication, she's no longer in that range to the normal A1c. She has better energy, she's sleeping better, she feels more engaged and just focused even in productive and her work because she no longer has that what she called "food brain" as I mentioned. I've seen just really fantastic and I saw her recently. That's what she comes to mind. Fantastic results.

Maureen Chomko: I think that the usefulness of our dietician or nurse 60 minute visits is we can discuss 100% of their lifestyle. You know, as Colleen was mentioning, I talk about sleep with many of my patients I have referred or not myself, but I've recommended that PCP refer for sleep apnea assessment in many of my patients that they have never talked about that with their doctor, there's just not enough time. We talk about stress management, and I integrate our behavioral health team in my clinic. So I think what is really useful about the diabetes educator role, the dietician, or the nurse embedded in clinic, that we can talk to these patients about all the things that get in the way of a potential weight loss or just improvement in health. These GLP-1s are one tool of that, but we are doing 360 lifestyle management that they don't often have time to talk about with their providers, and we have dedicated time to address whether it's like I said, sleep stress, or if it's other social determinants of health, we're able to help support the patient in all the ways that they need. This is one of our tools that we use that can make it so much easier to lose weight. Talking about with all the tools that we've already worked with our patients. It's just actually helping combat all the hormonal changes that persist when we start reducing calories. Behavioral interventions are really difficult to combat our body's hormones when we want to maintain our weight. So this is a great tool to help. All the suggestions dietitians have been recommending for years but it's just kind of coming in with a heavy hitter GLP-1 that help that food brain and help those recommendations stick.