Recognizing and Managing Comorbidities in Diabetes

Troy Trygstad, PharmD, MBA, PhD: If we step back for a second, from all of the mechanisms of action of the drugs, we have this reality that very few people just have diabetes. They either have another underlying disease state that hasn’t yet been diagnosed, or they have a formal diagnosis. We were on a prior Peer Exchange® panel with you, Tripp. You had mentioned that you’d started to administer PHQ-2s and PHQ-9s in patients with diabetes, and that you saw this effect where this was a really good way for us to figure out who needed additional support. Do you want to describe that? I’m hearing that it’s actually pretty rare for you to have a patient, who walks in, who you’re level-setting with—where it’s straightforward diabetes, right? Is there even straightforward diabetes? So, to the issue of all of these comorbid states, and to Dr. Morales’ point, you may focus on the severe persistent mental illness as the issue of the day because it’s very prominent, and has its effects. You may be focused on the heart failure or the cardiovascular disease because they just had a heart attack a few months ago. But in many cases, for these patients who are diabetic, it’s just this steady progression over time. How do you bring that diabetes to the fore, in that patient discussion, when so often there are other comorbid states that, within the minds of the caretaker or the patient, may take precedence?

Tripp Logan, PharmD: That is the challenge, right? The folks who come in, and sit down with the pharmacist, in our pharmacies, are typically the most complex. They’ve got multiple things going on. Patients tend to compartmentalize these things. They think, 'I’m going to manage my diabetes.' Or, 'I’m going to manage my cardiovascular disease.' One of the advantages that we have is that the therapy’s already been initiated when they come in to see us. And so, we get to have the talk. 'This is a marathon, not a sprint. You completely overhauled your diet, and changed your lifestyle. The chances are, it’s like quitting smoking—you’re going to relapse, at some point. So, we really need to play the long game here.' Another thing we do is talk about the availability of the community pharmacy with all of the touch points that we have. Patients may be in your office several times a year. We get to see these patients a lot—monthly, if not more often. And, we’re in their homes. So, we try to leverage that in any way that we can. Also, we use the support system that’s around us. And so, with this patient who comes in with a new diagnosis, or a new regimen, we talk to him or her not only about the longevity of how we can help manage this, but also bring in the support team from the community, as well—whether it’s the local health department, with dieticians… We bring those folks in. We enroll patients in our diabetes classes, and so forth. In one of our diabetes classes that we had, we brought in a speaker. The speaker was a local optometrist who had a daughter who was type 1 diabetic. I think she was diagnosed at the age of 8 or 10. And so, he gave a very compelling story, not only from his experience in doing eye exams, but also with his daughter. He said, 'You know, this is the only chronic condition, that I can think of, which can be solved up here. With lifestyle modification, and you think of hypertension and heart failure, you know you can’t overcome a lot of it up here. But, once you get going, up here, you really can do a lot of good with lifestyle modification, exercise, carbohydrate counting, and so on.' So, those daily challenges, and getting family members in, and really making this a team effort—that’s where we hope we’re bringing benefit to this whole package.

Javier Morales, MD, FACP, FACE: That was actually pretty nicely depicted in a trial that was conducted. It’s actually an NIH-sponsored trial, called the Look AHEAD study. The patients who were intensively treated with lifestyle modification, reduced caloric diet, had a 0.6% reduction in A1C. Their level of fitness also improved by 10 METs, which is really impressive. So, lifestyle is really the cornerstone. Aside from all of this, diabetes could be a pretty devastating illness, but it doesn’t need to be. I think that most patients tend to feel recluse once they’ve been issued this diagnosis. It’s equally important to recognize how every member of the care team, including the nutritionist, and especially the pharmacist, can play such an important role in ensuring adherence to therapies that are prescribed for our patients, and to encourage them to continue on their journey toward good control.

Tripp Logan, PharmD: With a lot of the touch points that we have in the community, we get to pick up on a lot of things. I failed to mention the depression screenings that we’ve done. That was one of our resident projects, and we continued that multiple times after. A lot of people go in and are diagnosed with diabetes. They come out with medicine, but they come out with diabetes and depression. So, those are things that we have to take into account, as well, and not treat the illness, but treat the entire patient and try to look for these things that may have been overlooked. The appointment may have been for diabetes, or it may have been with an endocrinologist, where they had a lot of other things going on that may be more acute. It puts us in a really intriguing position when we sometimes send referrals for things that we pick up on in the community, or even in the home, that may have been overlooked because of the really hyperfocused appointment.