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In the context of the COVID-19 pandemic, researchers investigated how insulin use and glycemic control were associated among patients with type 2 diabetes. 

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journal explores issues within pharmacy, from the impact advocacy can have in community pharmacies to staffing shortages across multiple sectors within pharmacy. This month’s issue also explored the importance of disease awareness months and how they are opportunities to maximize valued care. Check out a preview of this month’s issue here.

download the PDF of the Total Pharmacy August 2024 issue here

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See what’s trending in pharmacy with a preview of the Total Pharmacy August issue.

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In This Issue: Total Pharmacy August 2024

Combining sodium glucose co-transporter 2 inhibitors (SGLT2is) with glucagon-like peptide-1 receptor agonists (GLP-1RAs) may offer additional protection against cardiovascular and kidney disease in patients with type 2 diabetes (T2D), according to the results of a new meta-analysis published in 

 and presented at the 61st European Renal Association Congress in Stockholm, Sweden.

Separately, SGLT2is and GLP-1RAs have demonstrated cardiovascular benefits. However, little clinical literature has focused on outcomes associated with using the medicines together. Due to the growing prevalence of GLP-1RAs in the 

 and obesity landscape, accelerated by an increasing number of indications for the agent class, this is a crucial area for further study.

The SGLT2 Inhibitor Meta-analysis Cardio-Renal Trialists’ Consortium (SMART-C) is the largest assessment of outcomes for the combined therapeutic use of SGLT2is and GLP-1RAs. The study gathered data from 12 large-scale, placebo-controlled trials of SGLT2is involving 73,238 patients with diabetes. Of these, 3065 were already receiving GLP-1RAs.

Overall, SGLT2is lowered the risk of major adverse cardiovascular events by 11% and hospitalization for heart failure or cardiovascular death by 23% compared to placebo. Notably, this benefit was seen regardless of whether patients were also taking GLP-1RAs.

When used together with GLP-1RAs, SGLT2is reduced the risk of chronic kidney disease progression by 33% and slowed the annual loss of kidney function by nearly 60%.

The study found no additional safety concerns when SGLT2is were used in combination with GLP-1RAs.

Study Reveals Robust Benefits of Semaglutide in Protecting Against Kidney, CV Events in Patients With T2D

Current meta-analysis results build off positive results of the landmark FLOW trial (

). Published earlier in May, results of the international, double-blind, randomized, placebo-controlled phase 3 trial spotlighted semaglutide’s effectiveness in lowering the risk of kidney failure, decelerating worsening kidney function, and protecting against the risk of cardiovascular events and death, in patients with T2D.

“SGLT2 inhibitors have clear protective effects against heart failure and chronic kidney disease, while GLP-1 receptor agonists can reduce the risk of heart attack, stroke, and also kidney disease—as recently demonstrated in the landmark FLOW trial,” said Brendon Neuen, lead author, clinical associate professor, senior research fellow at The George Institute for Global Health, and director of kidney trials at Sydney’s Royal North Shore Hospital, in a news release.

 “Our findings support using this combination to further improve outcomes in patients with type 2 diabetes who meet guideline recommendations for both therapies.”

Elevated glucose from diabetes can damage blood vessels in the heart and kidneys, increasing the risk of 

 and kidney disease. In fact, diabetes is the most common cause of chronic kidney disease.

Moreover, estimates predicting that T2D prevalence will more than double in the next 30 years, surpassing 1 billion global cases by 2050, further strengthen the need for research into diabetes care.

 According to Neuen in an interview with 

 conducted over email, the current study offers valuable insights for developing global treatment strategies for the condition.

"These findings, which represent the largest and most comprehensive evaluation of the combined use of SGLT2i and GLP-1RA, provides the clearest evidence yet that combined use of both medicines can further reduce cardiovascular and kidney disease," said Neuen. "We anticipate that these findings will inform how people with diabetes are treated worldwide, including influencing major clinical practice guidelines.

Although current results suggest that using SGLT2is and GLP-1RAs in tandem may offer robust protection against cardiovascular and kidney disease, further research is needed to fully understand the long-term effects of the combination therapy.

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1. Apperloo E, Neuen BL et al. Efficacy and safety of sodium glucose co-transporter 2 inhibitors with and without glucagon-like peptide-1 receptor agonists: A SMART-C collaborative meta-analysis of randomised controlled trials. 

. 2024. doi: 10.1016/S2213-8587(24)00183-9

2. Massaro L. Study reveals robust benefits of semaglutide in protecting against kidney, CV events in patients with T2D. 

https://www.drugtopics.com/view/study-reveals-robust-benefits-of-semaglutide-in-protecting-against-kidney-cv-events-in-patients-with-t2d

3. Combining popular diabetes drugs offers complementary heart and kidney benefits. News release. The George Institute for Global Health. July 9, 2024. Accessed July 10, 2024. 

https://www.georgeinstitute.org/media-releases/combining-popular-diabetes-drugs-offers-complementary-heart-and-kidney-benefits

4. Mayo Clinic Staff. Chronic kidney disease. Fact sheet. Accessed July 8, 2024. 

https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-20354521

5. Klein HE. Diabetes prevalence expected to double globally by 2050. 

https://www.ajmc.com/view/diabetes-prevalence-expected-to-double-globally-by-2050

When used together, sodium glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) were able to lower the risk of major adverse cardiovascular events and kidney disease by 11% and 33%, respectively.

Clinical

SGLT2i, GLP-1RA Combination Therapy Offers Robust Protection Against Cardiovascular, Kidney Disease

Pharmacists are vital in abortion care medication, offering counseling, dosing guidance, and clinical oversight. They also support evidence-based practices through education and advocacy. However, varying state laws and legal restrictions pose major challenges. Staying informed and trained is essential for pharmacists to effectively support safe, accessible abortion care in their communities.

 recently sat down with Nicole Cieri-Hutcherson, PharmD, BCPS, MSCP, FCCP, clinical associate professor at the University at Buffalo, to discuss how pharmacists can support patient counseling and education around abortion medication, what types of training or continuing education could better prepare pharmacists to safely dispense medication, and the most significant challenges pharmacists might face in implementing abortion medication services.

: How can pharmacists support patient counseling and education around medication for abortion?

Nicole Cieri-Hutcherson, PharmD, BCPS, MSCP, FCCP

: There [are] a lot of [ways in which] pharmacists can provide patients with information,...not only in community pharmacy settings, where this is allowed..., but also in other settings, such as a hospital or an emergency department. As a highly trained health care professional, a pharmacist can not only dispense the medication, but talk the patient through how the therapeutic indication works, how the medication works, interactions, [adverse] effects to expect, what to expect with bleeding, and those very rare other [adverse] effects that might occur that are part of the medication guide.

In hospital or emergency departments, the pharmacist can serve as a safety checkpoint for any mifepristone and misoprostol orders, making sure that the indication is appropriate, that the dose is appropriate, being involved in the REMS [Risk Evaluation and Mitigation Strategy] program, and monitoring for safety. In addition, pharmacists can really work within a health care system to be an advocate for evidence-based medication care and evidence-based medication abortion care. They can provide their expertise in terms of protocol development, guideline development, and advocacy work in ensuring access to abortion medication.

: What types of training or continuing education could better prepare pharmacists to safely dispense abortion medication?

: There [are] a lot of different trainings that are available. I'd say that most of them are through private organizations, but sometimes it's as simple as just taking an updated continuing education program on abortion medication care. A couple that I've taken myself that I think were well done include Birth Control Pharmacist––they have some great resources and in their community, on their website––as well as ACOG [American College of Obstetricians and Gynecologists] and the National Abortion Federation. Then there [are] a couple of other private groups out there that provide education about how to counsel a patient on abortion medication, what to expect, [and] variations in state laws. One of the things that I will say is that if you're looking to provide this type of care, make sure that you're aware of the laws within your state and federally, the things that govern your ability to dispense and provide this type of care for patients.

: What are the most significant challenges pharmacists might face in implementing abortion medication services, and how can these be addressed?

: The most significant challenges that pharmacists face are related to the ever-evolving legislation involving abortion medication care. There are state laws that ban or restrict abortion and abortion medication, and they don't just apply to abortion procedures. It can apply to the abortion medication as well. There are large sections of the country that ban abortion, and even though federally the FDA has approved mifepristone and said that it's safe and effective following the Dobbs decision, and even prior to the Dobbs decision, there are restrictions on providing abortion medication in different states and who can provide that in a state.

There are other ways that states can restrict access to abortion medication, and sometimes that involves blocking the use of telehealth abortions or mandating inpatient...patient visits. Sometimes it involves pharmacists, especially if they're dispensing or counseling on abortion medication. As part of the steps that have been taken to limit abortion access, some states have taken action against pharmacists providing abortion medication. As I said before, it's really important to know what your state laws are, what's currently banned, and what legislation is in progress, so that you can get involved in that and continue to provide evidence-based...care for your patients.

Pharmacists Play Key Role in Expanding Access to Medication Abortion

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Pharmacists play a key role in medication for abortion care by providing clinical guidance, patient counseling, and advocacy.

Q&A: Pharmacists Help Close Gaps in Abortion Medication Access

Immunization Services Paramount for Community Pharmacy Sustainability

Immunization services in the US have recently risen as the one medical necessity provided mainly at community pharmacy locations, opening the door for greater pharmacy sustainability amid an increasingly concerning financial landscape.

“Ask yourself why you're vaccinating, and if you're not vaccinating, why you're not vaccinating,” Hashim Zaibak, PharmD, told 

. “If you're not vaccinating today, what are the obstacles? Do you need to maybe hire more people, maybe change the workflow?”

According to Zaibak, founder and CEO of Hayat Pharmacy in southeastern Wisconsin, self-inflection is the first step for any pharmacy location or group looking to begin expanding vaccination services, or for locations that aren’t vaccinating to begin with. Aside from the notable benefits of boosting vaccine awareness and uptake among the community, offering immunization services is a sure-fire way to increase revenue opportunities for pharmacy businesses.

“When I think of a good pharmacy, I'm always thinking of a pharmacy that offers good services that will help the patients live healthier and longer, and vaccine is always one of them,” continued Zaibak, who sat down with 

Explore Zaibak’s insightful advice and understand just how important vaccines are to community pharmacy, as well as how crucial community pharmacies and their employees are for vaccine uptake and infectious disease rates in the US.

Community Pharmacy’s Pivotal Role in Boosting Immunization Rates

Are you ready to elevate your pharmacy practice? Sign up today for our 

During National Immunization Awareness Month, Hashim Zaibak, PharmD, provided personal tips for community pharmacies looking to expand their vaccination services.

Sulfonylureas were associated with an increased risk of cardiovascular events in patients with type 2 diabetes (T2D) compared with dipeptidyl peptidase 4 (DPP4) inhibitors, according to data published in 

The study, which found the risk was highest for glipizide, suggests sulfonylureas may not be the best choice of medication for patients with T2D who have moderate cardiovascular disease risk.

Sulfonylureas are affordable and effective glucose-lowering agents used for decades in T2D management. However, concerns remain about their cardiovascular safety, based on data from older trials and observational studies showing a higher risk compared with other medications. Additional drawbacks such as hypoglycemia, weight gain, and reduced durability challenge their use as second-line therapy.

“Patients with type 2 diabetes are at heightened risk of adverse cardiovascular incidents such as stroke and cardiac arrest,” Alexander Turchin, MD, MS, corresponding author on the study, said in a release.

 “While sulfonylureas are popular and affordable diabetes medications, there is a lack of long-term clinical data on how they affect cardiac health in comparison to more neutral alternatives like dipeptidyl peptidase 4 inhibitors.”

Investigators from Harvard Medical School and Brigham and Women’s Hospital conducted a study to compare the risk of cardiovascular events after starting treatment with individual sulfonylureas or DPP4 inhibitors. The comparative effectiveness study included 48165 patients with T2D and moderate cardiovascular risk who were treated at 1 of 10 health systems in the United States between January 2013 and January 2023.

The patients all received metformin monotherapy and then initiated either glimepiride, glipizide, glyburide, or any DPP4 inhibitor, including alogliptin, linagliptin, saxagliptin, or sitagliptin. The primary study outcome was the 5-year risk of a 4-point composite of major adverse cardiovascular events (MACE-4), which included myocardial infarction, ischemic stroke, heart failure hospitalization, or cardiovascular death.

During the study, 18147 patients started glipizide, 14282 started glimepiride, 1887 started glyburide, and 13849 started a DPP4 inhibitor. The study found that over a median follow-up time of 37 months, 6.6% of patients experienced a MACE-4: 2.2% had myocardial infarction, 2.6% had an ischemic stroke, 3% had a heart failure hospitalization, and 0.4% died from any of the conditions. Compared with DPP4 inhibitors, the 5-year risk ratio of MACE-4 was 1.13 for glipizide, 1.07 for glimepiride, and 1.04 for glyburide.

Study limitations included a short median follow-up time, which made it difficult to detect further differences between the medications; the fact that gliclazide was not in use during the study; and the fact that racial and ethnic diversity was limited.

“The potentially different cardiovascular risk between individual sulfonylureas in our study underscores the importance of evaluating each agent in a particular pharmacological class on its own merits,” the authors concluded. “These findings caution against extrapolating results of studies evaluating a single agent to the entire class, and temper concerns about the use of research and development resources for the development of multiple agents in the same pharmacological class.”

1. Turchin A, Petito LC, Hegermiller E, et al. Cardiovascular events in individuals treated with sulfonylureas or dipeptidyl peptidase 4 inhibitors. 

 2025;8(7):e2523067. doi:10.1001/jamanetworkopen.2025.23067

2. Wang H, Cordiner RLM, Huang Y, et al. Cardiovascular safety in type 2 diabetes with sulfonylureas as second-line drugs: a nationwide population-based comparative safety study. 

3. Study compares common type 2 diabetes drugs, finding higher cardiovascular risk for one medication. News release. Mass General Brigham. July 24, 2025. Accessed August 5, 2025. 

https://www.massgeneralbrigham.org/en/about/newsroom/press-releases/cardiovascular-risk-of-diabetes-drugs

Patients with type 2 diabetes and moderate cardiovascular risk had a higher rate of major heart-related events when treated with sulfonylureas.

Glipizide Increases Cardiovascular Risk Compared With DPP4 Inhibitors in T2D

Metformin, a drug primarily used for the treatment of diabetes, has been thought to provide clinical benefits extending to neurodegenerative conditions, including Alzheimer disease (AD). However, results published in 

 showed that metformin may not be the optimal pharmacologic agent for patients with diabetes who are trying to target neurodegeneration as their primary concern.

“Metformin's use for DM [diabetes mellitus] treatment is generally considered to be a first-line option due to affordability, accessibility, and effectiveness in lowering [hemoglobin] A

, as evidenced here with patients having taken metformin having reduced values when compared to sulfonylureas and short-acting insulins, with differences of 0.1% and 0.56%, respectively,” the study authors wrote.

article, investigators conducted a systematic review and meta-analysis to determine if metformin could prevent cognitive dysfunction, with results showing that the occurrence of cognitive decline decreased for patients with diabetes, but only for the prevention of dementia and not AD. Further, from the authors of a study in 

metformin use did correlate with slower decline on a score of global cognition compared with patients who did not use metformin. However, when examining any diabetes medication, there was no association observed for diabetes medication and cognitive function compared with no diabetes medication.

In the current study, investigators compared metformin, glucagon-like peptide-1s (GLP-1s), insulin, and sulfonylureas for hemoglobin A

New research shows metformin's inconsistent neuroprotective effects against Alzheimer disease, challenging its role in diabetes management for cognitive health.

Beth Brooks, PhD, RN, FACHE

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