Cardiometabolic disorders: The pharmacist's role

September 4, 2009

The term "cardiometabolic disorders" (CMD) refers to a cluster of interrelated risk factors (hypertension, elevated fasting glucose, reduced high-density lipoprotein, elevated triglycerides, and abdominal obesity) that promote the development of atherosclerotic cardiovascular disease and type 2 diabetes. With an estimated 47 million Americans facing increased risk of heart disease because of these conditions, management of patients' CMD is a priority for pharmacists.

Key Points

Pharmacists have an essential role to play in managing CMD&W through teaching, counseling, and dispensing.

Guidelines

"One thing that most providers agree upon," she said, "is the need for prevention and early detection of the [associated] risk factors." This is where community pharmacists can help mitigate the causes and symptoms of CMD&W by engaging and coaching patients, in addition to imparting their knowledge about medications.

Role of pharmacists

With many drugs, adherence is a growing problem, and the medications associated with CMD&W - statins, antihypertensives, and diabetes drugs - are no exception. Nonadherence occurs in 21.3 percent of patients with diabetes, according to a retrospective cohort study of 11,532 patients.3 The study revealed that those who did not adhere to their prescribed antihypertensive, hypoglycemic, and lipid-lowering medications at least 80 percent of the time were significantly more likely to have elevated levels of HbA1c' blood pressure, and LDL than were those who adhered.

The American Pharmacists Association recommends that pharmacists collaborate with physicians to identify individuals who are not adherent and help to eliminate barriers by minimizing the number of daily doses, reducing dosing frequency, and selecting the most efficacious and cost-effective medications.

Alan Vogenberg, RPh, a consultant pharmacist in Levittown, Penn., says that community pharmacists are at a loss, because they know what drugs patients are taking, but they don't necessarily know the diagnosis. This can make it difficult to counsel them. "The best-case scenario is developing a collaborative approach with a physician and creating a dialogue," he told Drug Topics.

"The pharmacist can monitor patients and report back to the physician. We can serve as teachers and help patients manage side effects or facilitate compliance. Also, don't use jargon with patients; use open-ended questions and ask patients to repeat back information to ensure they understand what has been said."

Tracey H. Taveira, PharmD, associate professor of pharmacy at the University of Rhode Island in Kingston, agrees with Vogenberg that as patients take more drugs as part of increasingly complex regimens, pharmacists can play an important role in medication adherence. "We are also experts at knowing what's on formulary, helping to ensure that drugs are covered, and converting doses and medications if needed," she said.

Through an affiliation with the Veterans Affairs Medical Center in Providence, Taveira and her colleagues conducted a study of 375 veterans, using the Cardiovascular Risk Reduction Clinic model,4 a pharmacist-coordinated care model that incorporated cardiometabolic risk factors under one umbrella for treatment by clinical pharmacists overseen by a cardiologist. Participants underwent motivational interviewing geared to modifying their behavior and received frequent medication titrations, which clinical pharmacists were allowed to modify under federal regulation.

In accordance with guidelines recommended by the American College of Cardiology/AHA and the American Diabetes Association, 70.7 percent met the discharge criteria by the end of the study period. Guideline adherence increased for total cholesterol, LDL, HDL (high-density lipoprotein), HbA1c (a measure of blood glucose over time), and systolic blood pressure.