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With hypertension commonly leading to increased risk of mortality, researchers aimed to understand the hypertensive survival rates of patients with diabetes over a 20-year period.

Hypertension Mortality Rose Significantly from 1999 to 2019

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Regardless of which stakeholders are involved, a collective, team effort is necessary to achieve state- and federal-level PBM reform.

Achieving PBM Reform Through Public Engagement, Advocacy

CVS will not offer COVID-19 vaccines in Massachusetts, Nevada, and New Mexico.

CVS, Walgreens Will Limit COVID-19 Vaccine Offerings in 16 States

A real-world study found that semaglutide significantly reduced the risk of major cardiovascular events compared to tirzepatide.

Wegovy Outperforms Tirzepatide in Reducing Major Adverse Cardiovascular Events

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GPS-based dietary prompts, continuous glucose monitors among the devices poised to revolutionize diabetes treatment and patient management. 

The Smart Technology That Will Change Diabetes Care

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.

Total Pharmacy

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

Direct-to-consumer (DTC) pharmacies could reduce total prescription drug costs but not out-of-pocket costs, according to study results published in 

. The investigators specifically explored the cost of neurological medication in DTC business models compared with coverage from commercial insurance plans.

“We found that the direct-to-consumer pharmacy commonly had lower total costs, in some cases much lower, for commonly used generic neurologic medications (except for diflunisal, nortriptyline, and fludrocortisone),” the study authors said.

 “However, even when total costs were much lower, this did not translate into lower OOP [out-of-pocket] costs for patients with commercial insurance.”

DTC pharmacies often sell drugs that have a generic alternative, usually at lower prices than traditional retail pharmacies, but not all drugs are available. In study data published in the

, investigators showed that 94 of 118 expensive generic dosage forms were available at 1 or more DTC pharmacies. Of the 52 common generic dosage forms, all but 1 were available. Amazon Pharmacy, Mark Cuban Cost Plus Drug Company, Health Warehouse, and Costco had the lowest expensive generic costs, respectively. However, the investigators noted that many of the most expensive generic drugs are unavailable at DTC pharmacies.

Online pharmacy and telepharmacy have been more convenient methods for medication management to enhance care, according to authors of a study in the 

 In outpatient settings, teleneurology showed increased access to specialized care for patients in rural locations, and in the findings from this study, investigators showed that telemedicine is also feasible in underserved populations in urban areas. Further, they stated that there are opportunities to expand these services to address barriers to medication adherence.

In DTC pharmacies, the model could lower prices of medication by selling directly to patients because it could bypass the need for insurance and pharmacy benefit managers. In the current study, investigators evaluated pharmacies that mainly carried generic medications, and they compared the 2024 neurological costs with commercial plans with DTC pharmacies. Investigators used a retrospective cross-sectional study that compared Mark Cuban Cost Plus Drug Company with commercial insurance plan costs of various neurological medications.

Data from commercial insurance plan costs were gathered from 2012 to 2021, including Merative Market Scan commercial and Medicare supplemental databases. Data on DTC pharmacy were obtained on December 10, 2024, and investigators used a 3-month supply for each medication. Patients with a diagnosis of epilepsy, multiple sclerosis, Parkinson disease peripheral neuropathy, dementia, Alzheimer disease, amyotrophic lateral sclerosis, transthyretin amyloidosis, Duchenne muscular dystrophy, Huntington disease, myasthenia gravis, migraine or headache, orthostatic hypotension, tardive dyskinesia, or spinal muscular atrophy were all included.

Of 79 neurological medications, investigators included 33 that were available for purchase through DTC pharmacies. The results showed that DTC pharmacy out-of-pocket costs were approximately 75% higher, but total costs were 413% lower than commercial insurance plans. Medications with the highest insurance plan annual out-of-pocket costs were teriflunomide ($286), droxidopa ($238), fingolimod ($240), dimethyl fumarate ($207), glatiramer acetate ($203), and tetrabenazine ($172) in 2024; similarly, the total costs were $11,739, $11,618, $8394, $6698, $6759, and $5040, respectively. For DTC, the most expensive medications were glatiramer acetate ($24,186), fingolimod ($2185), and cyclosporine ($2185), with the remaining medications being less than $635 annually.

“For most of the neurologic medications observed, the direct-to-consumer pharmacy total cost is estimated to be less than that of commercial insurance plans,” the study authors concluded.

 “The largest aggregate total cost savings were for teriflunomide, fingolimod, and dimethyl fumarate, with aggregate savings estimated at a minimum of $11 million each by using the direct-to-consumer pharmacy instead of commercial insurance plans at a retail pharmacy.”

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1. Gusovsky Chevalier AV, Lin CC, Kerber K, Reynolds EL, Callaghan BC, Burke JF. Neurologic medication costs in a direct-to-consumer pharmacy vs commercial insurance plans. 

 2025;8(8):e2527476. doi:10.1001/jamanetworkopen.2025.27476

2. Lalani HS, Tessema FA, Kesselheim AS, Rome BN. Availability and cost of expensive and common generic prescription drugs: a cross-sectional analysis of direct-to-consumer pharmacies. 

. 2024;39(12):2187-2195. doi:10.1007/s11606-024-08623-y

3. Li H, Naqvi IA, Tom SE, Almeida B, Baratt Y, Ulane CM. Integrating neurology and pharmacy through telemedicine: a novel care model. 

. 2022;432:120085. doi:10.1016/j.jns.2021.120085

DTC pharmacies offer significant savings on total medication costs for neurological drugs, but out-of-pocket expenses remain high for insured patients.

Direct-to-Consumer Pharmacies May Reduce Total Prescription Price for Neurological Medication

Consistent insulin therapy has the potential to significantly maintain glycemic control during health care disruptions, such as during the COVID-19 pandemic, according to data from a study published in 

 Researchers’ findings show that the integration of telehealth and pharmacist-led interventions can bolster diabetes care during major health care emergencies.

“The onset of the COVID-19 pandemic in March 2020 triggered widespread disruptions across health care systems worldwide, posing challenges for individuals managing type 2 diabetes (T2D),” wrote the study authors. “The implementation of public health measures, including lockdowns and social distancing protocols, potentially hindered access to routine medical care and medications, exacerbating the difficulties faced by [patients with] diabetes.”

While the impact of the COVID-19 pandemic affected patients and providers worldwide, pharmacists were placed in an unprecedented position once lockdowns were enforced. One of the most important roles pharmacists took on during the pandemic was as immunizers, providing increased access to the COVID-19 vaccine in minimal time.

Aside from distributing vaccines at life-saving rates during the pandemic, many pharmacists also became experts on drug-supply chains, telehealth services, ambulatory pharmacy services, digital software, dispelling misinformation, and more.

Q&A: Pharmacists Play Key Role in Expanding Access to CGMs

Furthermore, on top of the role pharmacists undertook to combat COVID-19, they have also exhibited significant expertise in the diabetes space before, during, and after the pandemic. According to study findings published in 

, pharmacists’ roles have evolved, making pharmacists the key administrators of 5 tasks within diabetes care. Those roles include disease state management, medication review, cost containment, preventive care, and medication adherence.

Although the prominence of diabetes is growing, along with the need for providers to manage patients’ diseases, few data exist on managing insulin for patients with diabetes during a public health emergency that disrupts normal flows of care.

“The objective of this retrospective cohort study is to assess the association between insulin use and glycemic control, as measured by changes in hemoglobin A

 levels, among patients with T2D during the COVID-19 pandemic,” the authors continued.

 “This study also explores patterns of medication use that may have contributed to changes in [hemoglobin] A

The researchers conducted a retrospective analysis of clinical and prescription drug data from family medicine clinics. Their main time frames included the pre–COVID-19 period from March 1, 2019, to March 13, 2020, and the period during the pandemic, from March 14, 2020, to March 31, 2021.

The researchers’ primary outcome was patients’ glycemic control, or their change in hemoglobin A

level defined as below 8%, patients were separated into 4 groups based on their HbA

status before and during the pandemic: uncontrolled, controlled, improved, or worsened. The researchers also explored insulin and noninsulin medication use during these periods, and whether or not patients increased, decreased, introduced, or discontinued medications during the pandemic.

A total of 992 patients (mean age, 56; 54.5% women) were included in the final analysis.

“As in other studies of patients [with diabetes] during the pandemic, we did not find a worsening of [Hb]A

 levels despite disruptions in care among the...patients in 2 safety net family clinics,” wrote the authors.

 “Our case series review showed that most patients whose [Hb]A

 improved were on insulin, compared [with] those whose [Hb]A

 worsened. During the COVID-19 era, this population experienced significant disruptions in diabetes management due to social distancing policies,...clinic closures, and other pandemic-related challenges.”

The most notable findings from the researchers’ review were that only a portion (24%) of patients saw any changes in their HbA

levels. Although 128 improved and 110 worsened, the main factor highlighted in those who saw improvements was insulin use, whether administered through telehealth services or pharmacist-led interventions.

The findings suggest that consistent insulin use for patients with T2D is the best approach for maintaining HbA

levels during future public health disruptions. Although not exclusive to emergency situations, telehealth services and pharmacist interventions took a leap forward and exhibited significant success in improving patient outcomes during the pandemic.

Future research will explore the pharmacist’s further role in managing diabetes during a health care disruption and other ways to ensure equity and resilience during events such as the pandemic.

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

Chuck Green

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