Pharmacist Role in Optimizing Diabetes Care

FEBRUARY 15, 2018


Troy Trygstad, PharmD, MBA, PhD; Dhiren Patel, PharmD; and Steven Peskin, MD, MBA, discuss pharmacy-led strategies to optimize care for patients with type 2 diabetes.

Troy Trygstad, PharmD, MBA, PhD: With respect to the therapeutics, we’ve talked a lot about, “Hey, even if you have the optimized regimen for the patient that goes beyond even the management of diabetes to behavioral health and cardiovascular disease, and so on, and so forth, it can fall apart.” We’ve talked about that a lot. Patients are dynamic. Patients might start on a good diet and exercise. They might end up in a different environment where they go one direction or the other. They may be in an environment where they were started on an SSRI and it hasn’t been titrated. What about the circumstance where we generally do have a patient that’s able to execute the care plan as formed? They come back to your exam room and their hemoglobin A1C is 11.5%. What do you do next?

Dhiren Patel, PharmD: Again, if that was the scenario, you’d obviously go through your checklist to decide where the discrepancy is coming from. If the patient was on therapy and adherence is not a factor, because that’s the one that usually screams out at me when I see something like that, it could be adverse events or patient factors. And so, when you look at an A1C of 11%, you’re thinking about insulin. But maybe it’s issues with hypoglycemia? It may be issues with weight gain or the sulfonylureas or other drugs that are causing weight gain. Are those the ones that are being prescribed? The patient figures it out within a month or two. “I’m not taking this.” I see a lot of those scenarios. What I always try to do is kind of optimize that regimen. I always ask the patient, “Where is it that you want to be?” We all know where we want them to be, but, “Where is it that you want to be?”

Sometimes I have patients that will come in to my clinic. They’ll quiz me a little. “Do you know what the average life expectancy of a male here in the US is?” I’ll give them a number. They’re like, “I’m 84” or “I’m 76.” They say, “Everything from this point onward is a bonus.” That’s fair. And so, that’s why I ask the question of, “Where do you want to be?” Because everyone has different goals and that’s OK. “Eight is good enough for you because you live by yourself and you have other comorbid conditions. If you do get a low blood sugar, it’s going to be a really bad event.” And so, that’s one of the reasons why we have our own guidelines and goals. We know that our patient population is different. It’s OK to let them be a little bit higher if they have comorbid conditions or limited life expectancy.

Troy Trygstad, PharmD, MBA, PhD: What’s fascinating about what you just said is, a patient-centered drug regimen or a patient-centered care plan may not be focused on patient goals as we think of them—as the traditional conventional medical model with clinical biomarkers—but, rather, set a chart for what are we trying to accomplish, at the end of the day, with this patient? And then, thinking about the drug regimen as, “Here’s an array of patient goals that I have from the last visit. Where are we at? Are these still your goals?” And then, “Do we need to tweak the regimen?” First, “Are we following the regimen?” But then, “Do we need to tweak the regimen in any way because we’re not tracking toward those goals?” Don’t make the assumption that the goals are as you see fit. It’s the goals as they see fit.

Dhiren Patel, PharmD: It has to be that way. If you think about it, we have more drug classes in diabetes than we ever had. They’re all better than the prior ones, with less hypoglycemia and less weight gain. But from a population health standpoint, we’ve not moved the needle. So obviously it’s not, “We don’t need more.” There’s something else, and I think it’s worth a try because the other stuff has not worked up until now.

Troy Trygstad, PharmD, MBA, PhD: Steven, you’ve got a list of patient goals. The patient was in 3 months ago. They did a repeat lab. They walk in and their hemoglobin A1C is not where it should be at. And maybe they’re not happy with some of their other patient goals. You feel like you’ve done some investigation and they generally followed the care plan and the drug regimen that you set pretty well. What do you do next? Again, it’s almost like the quarterback checking down. The primary is not working. What’s secondary? What’s tertiary? What does that process look like in your mind?

Steven Peskin, MD, MBA: As internists, we’re certainly going to leap to medication intensification or optimization. That’s just how we roll. So, we’re certainly going to do that. We’re certainly going to talk about nutrition. In the clinical setting, where I am, we’re a FQHC (Federally Qualified Health Center), so, dissimilar to the VA setting. We have a bit more expansive set of services. We have a PharmD who is our primary coach. We’re certainly going to invoke her help and support for nutritionally based care.
In some instances, we might do a home visit to really understand what the home environment looks like. That can be a very, very illuminating, and some of our residents do that. More in family medicine, I’ll give you a shout out. That would be another part in an idealized state. But the 2 things we would really look at are medication intensification or optimization and then diet.

Troy Trygstad, PharmD, MBA, PhD: Well, I’m just happy that we’ve reached peace between internists and family medicine.

Steven Peskin, MD, MBA: I went mostly with family doctors. That’s my work. They’re in the driver’s seat in a medical home.
 


Troy Trygstad, PharmD, MBA, PhD; Dhiren Patel, PharmD; and Steven Peskin, MD, MBA, discuss pharmacy-led strategies to optimize care for patients with type 2 diabetes.

Troy Trygstad, PharmD, MBA, PhD: With respect to the therapeutics, we’ve talked a lot about, “Hey, even if you have the optimized regimen for the patient that goes beyond even the management of diabetes to behavioral health and cardiovascular disease, and so on, and so forth, it can fall apart.” We’ve talked about that a lot. Patients are dynamic. Patients might start on a good diet and exercise. They might end up in a different environment where they go one direction or the other. They may be in an environment where they were started on an SSRI and it hasn’t been titrated. What about the circumstance where we generally do have a patient that’s able to execute the care plan as formed? They come back to your exam room and their hemoglobin A1C is 11.5%. What do you do next?

Dhiren Patel, PharmD: Again, if that was the scenario, you’d obviously go through your checklist to decide where the discrepancy is coming from. If the patient was on therapy and adherence is not a factor, because that’s the one that usually screams out at me when I see something like that, it could be adverse events or patient factors. And so, when you look at an A1C of 11%, you’re thinking about insulin. But maybe it’s issues with hypoglycemia? It may be issues with weight gain or the sulfonylureas or other drugs that are causing weight gain. Are those the ones that are being prescribed? The patient figures it out within a month or two. “I’m not taking this.” I see a lot of those scenarios. What I always try to do is kind of optimize that regimen. I always ask the patient, “Where is it that you want to be?” We all know where we want them to be, but, “Where is it that you want to be?”

Sometimes I have patients that will come in to my clinic. They’ll quiz me a little. “Do you know what the average life expectancy of a male here in the US is?” I’ll give them a number. They’re like, “I’m 84” or “I’m 76.” They say, “Everything from this point onward is a bonus.” That’s fair. And so, that’s why I ask the question of, “Where do you want to be?” Because everyone has different goals and that’s OK. “Eight is good enough for you because you live by yourself and you have other comorbid conditions. If you do get a low blood sugar, it’s going to be a really bad event.” And so, that’s one of the reasons why we have our own guidelines and goals. We know that our patient population is different. It’s OK to let them be a little bit higher if they have comorbid conditions or limited life expectancy.

Troy Trygstad, PharmD, MBA, PhD: What’s fascinating about what you just said is, a patient-centered drug regimen or a patient-centered care plan may not be focused on patient goals as we think of them—as the traditional conventional medical model with clinical biomarkers—but, rather, set a chart for what are we trying to accomplish, at the end of the day, with this patient? And then, thinking about the drug regimen as, “Here’s an array of patient goals that I have from the last visit. Where are we at? Are these still your goals?” And then, “Do we need to tweak the regimen?” First, “Are we following the regimen?” But then, “Do we need to tweak the regimen in any way because we’re not tracking toward those goals?” Don’t make the assumption that the goals are as you see fit. It’s the goals as they see fit.

Dhiren Patel, PharmD: It has to be that way. If you think about it, we have more drug classes in diabetes than we ever had. They’re all better than the prior ones, with less hypoglycemia and less weight gain. But from a population health standpoint, we’ve not moved the needle. So obviously it’s not, “We don’t need more.” There’s something else, and I think it’s worth a try because the other stuff has not worked up until now.

Troy Trygstad, PharmD, MBA, PhD: Steven, you’ve got a list of patient goals. The patient was in 3 months ago. They did a repeat lab. They walk in and their hemoglobin A1C is not where it should be at. And maybe they’re not happy with some of their other patient goals. You feel like you’ve done some investigation and they generally followed the care plan and the drug regimen that you set pretty well. What do you do next? Again, it’s almost like the quarterback checking down. The primary is not working. What’s secondary? What’s tertiary? What does that process look like in your mind?

Steven Peskin, MD, MBA: As internists, we’re certainly going to leap to medication intensification or optimization. That’s just how we roll. So, we’re certainly going to do that. We’re certainly going to talk about nutrition. In the clinical setting, where I am, we’re a FQHC (Federally Qualified Health Center), so, dissimilar to the VA setting. We have a bit more expansive set of services. We have a PharmD who is our primary coach. We’re certainly going to invoke her help and support for nutritionally based care.
In some instances, we might do a home visit to really understand what the home environment looks like. That can be a very, very illuminating, and some of our residents do that. More in family medicine, I’ll give you a shout out. That would be another part in an idealized state. But the 2 things we would really look at are medication intensification or optimization and then diet.

Troy Trygstad, PharmD, MBA, PhD: Well, I’m just happy that we’ve reached peace between internists and family medicine.

Steven Peskin, MD, MBA: I went mostly with family doctors. That’s my work. They’re in the driver’s seat in a medical home.
 
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