Development of a Continuous Glucose Monitoring Service by Clinical Pharmacists in a Medically Underserved Population.

Background: Continuous glucose monitoring (CGM) is an evolving technology that provides a wealth of information to aid in managing diabetes. Professional CGM (ProCGM) is recommended when personal CGM is not desired or available. Patients in medically underserved areas may have limited access to personal CGM devices, thus ProCGM devices can be used for short-term monitoring and medication adjustment. Clinical pharmacists are well-positioned to help set up and establish personal and professional CGM management services. Objectives: To determine the effect of ProCGM in patients with persistently uncontrolled type 2 diabetes in a medically underserved population (MUP). Methods: Pre-post intervention analysis of a single cohort of patients in a public health center. Patients with persistently uncontrolled (A1c > 9%) and taking at least one daily dose of insulin were included. Included participants wore a ProCGM sensor and met with the clinical pharmacist at least once for ProCGM data interpretation and education. The primary analysis evaluated patients who achieved an A1c <9% 1-6 months after intervention. The change in A1c was also evaluated. Participants completed a pre- and post-survey about their experience. Results: Twenty-two patients were included in the final analysis. Ten patients achieved an A1c <9% (45%). The mean A1c pre- and post-ProCGM was 11.0% and 9.8% respectively, with a decrease of -1.2% (p=0.055) overall and a decrease of -1.7% for patients who wore the sensor for at least 10 days (p=0.012; n=15). Using the CGM data 91% of participants had a change to their medication regimen and 45% achieved an A1c <9%. Six participants experienced hypoglycemia per the CGM report, but only two were aware of it. After reviewing their glucose report with the pharmacist, 95% of the respondents agreed or strongly agreed to feeling more knowledgeable about blood sugar patterns after reviewing the report with a pharmacist. Conclusion: Almost half of the patients in the study achieved an A1c <9%. This study demonstrated glycemic benefit in patients in a MUP who wore a ProCGM for at least 10 days and met with a clinical pharmacist. Data from ProCGM enabled patients to better understand glucose patterns in those with persistently uncontrolled type 2 diabetes.

Clinical inertia among health care providers in a public health safety-net clinic in the management of type 2 diabetes.

BACKGROUND: Clinical inertia is defined as the lack of treatment intensification in patients who are not at evidence-based goals of therapy; it may be related to provider, patient, and health system-wide factors. Patient factors, including nonadherence and tablet burden, are further compounded by health and social disparities present in safety-net clinics. Clinical pharmacist-based interventions may impact provider or health system factors to reduce inertia in patients with poorly controlled diabetes. OBJECTIVES: To evaluate the rate of clinical inertia between health care providers in a safety-net clinic. METHODS: A single-center, cross-sectional, retrospective study compared 2 cohorts of adult patients with type 2 diabetes and glycosylated hemoglobin (A1C) greater than 8% in 2016. Diabetes care was provided by clinical pharmacists in the intervention group and by primary care providers in the control group. The primary outcome was the difference in clinical inertia, measured by pharmacologic treatment intensification between groups within 4 months following the first A1C greater than 8% of the study period. RESULTS: Of 276 eligible patients, 72 were in the intervention group and 204 in the control group. There was no statistical difference between baseline A1C between groups, with an average A1C of 10.01% for the study population. In the pharmacist group versus provider group, the rate of overall treatment, noninsulin, and insulin intensification was 79% versus 49% (P < 0.001), 40% versus 32% (P = 0.19), and 54% versus 19% (P < 0.001), respectively. Patients were contacted an average of 4 times during the follow-up period in the pharmacist group as compared to 1 time in the provider group (P < 0.001). CONCLUSION: In this safety-net clinic, pharmacist-based interventions reduced clinical inertia in patients with poorly controlled diabetes. Future studies evaluating inertia long term and the impact on glycemic goals are needed.

Glucagon-like peptide 1 receptor agonists in type 1 diabetes mellitus.

PURPOSE: The role of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) in the treatment of type 1 diabetes mellitus (T1DM), including efficacy and safety evidence, is reviewed. SUMMARY: Currently approved treatment options for glycemic control in T1DM include insulin, which combats insulin deficiency but does not effectively target disease progression or alpha cell dysfunction; and pramlintide, whose use requires multiple daily doses and involves a high likelihood of gastrointestinal side effects. GLP-1 RAs have a unique mechanism of action in T1DM, addressing alpha cell dysfunction and thereby suppressing inappropriate glucagon secretion. GLP-1 RA dosing varies from once weekly to twice daily, and the class is well tolerated in patients with type 2 diabetes. Among the GLP-1 RAs, exenatide and liraglutide have been studied in patients with T1DM, with published evidence consistently demonstrating weight loss, decreases in total daily insulin requirements, and modest improvements in glycemic control. GLP-1 RA therapy appears to be well tolerated in patients with T1DM and is associated with nonsignificant increases in hypoglycemia risk. CONCLUSION: GLP-1 RA therapy represents an important add-on therapy option for achieving decreased insulin doses, weight loss, and modest improvements in HbA1c levels without significantly increasing hypoglycemia risk in patients with T1DM. Patients who have detectable C-peptide and/or are overweight or cannot achieve glycemic goals without hypoglycemia have been found to benefit the most from GLP-1 RA therapy. Further studies are warranted to evaluate these agents' potential impact on clinical outcomes such as microvascular and macrovascular complications.

Semaglutide once-weekly: improved efficacy with a new safety warning.

INTRODUCTION: Semaglutide once-weekly glucagon-like peptide-1 receptor agonist (GLP-1 RA) injection has been approved as an adjunct to diet and exercise to improve glycemic control in type 2 diabetes mellitus (T2DM). Areas Covered: The safety and efficacy of the semaglutide once-weekly injection are reviewed using results from preliminary pharmacology studies and later-phase randomized control trials (RCTs) and meta-analyses. Semaglutide once-weekly is compared to placebo and active comparators for T2DM in the SUSTAIN clinical trial series, with outcomes of: glycemic control, weight loss, major adverse cardiovascular events, and adverse effects. Risk for diabetic retinopathy complications (DRCs) is reviewed in detail, due to significantly higher risk for DRCs seen in SUSTAIN 6. SUSTAIN 6 is the first instance of a GLP-1 RA demonstrating significantly increased risk for DRCs. Semaglutide's current regulatory approvals, practice considerations, and cost-effectiveness compared to similar therapies are also considered. Expert Commentary: Semaglutide demonstrates high glycemic efficacy and favorable safety profile, and reduces the risk for cardiovascular events. Mild to moderate gastrointestinal events and retinopathy complications were more common with semaglutide compared to placebo, though serious adverse events were similar to controls and infrequent. Improved clinical efficacy should be carefully weighed against the risk for GI and retinopathy complications.

Incorporating an internet-based voicemail drug information assessment in an introductory pharmacy practice course.

OBJECTIVES: To examine the implementation and student perceptions of an innovative verbal drug information assessment. DESIGN: The drug information assignment in an introductory pharmacy practice course was redesigned and an assessment of a verbal response to a drug information request was added with the use of an internet-based voicemail (IBVM) system. ASSESSMENT: Students performed well on both the verbal vs. written assessments. Most students strongly agreed or agreed that completing both assignments was a valuable experience; however, more students agreed that the verbal assignment was useful (90% vs. 83%). More students agreed that the verbal assignment helped prepare them as a pharmacist (97% vs. 85%) and that the verbal assignment increased their confidence (82% vs. 78%). Student comments echoed these results; additionally, many indicated that the verbal assessment was realistic. CONCLUSION: The IBVM assessment was successful, user-friendly, and this mode of assessment may be useful in other courses.