Optimizing Treatment Strategies for Diabetes - Episode 9
Jennifer D. Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP, discusses topics to address with patients to ensure appropriate self-administration of insulin.
Jerry Meece, RPh, CDCES, FACA, FADCES: How do you ensure that people are using insulin pens [correctly]? How often do we need to check on them? How do you follow up on what you’ve told them?
Jennifer D. Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP: Whenever possible, I try to have them do the first injection with me so that we teach them and they’re injecting. Give them something in writing to go home with. They might do a wonderful job sitting in front of you, but once they’re home alone, it might be different. Have something for them to refer to, to know what to do in that situation. We need to make sure they understand how to store the pens and the vials, how to utilize them, and where to inject.
It’s important to know where to inject. For example, the abdomen has a lot of real estate, but you can inject in your upper outer arms, your thighs, and your buttocks. It’s critical to make sure they know to rotate those sites. Particularly, someone with type 1 or type 2 diabetes using multiple daily injections needs to rotate those sites. Even with basal insulin once a day, you have to rotate your site, but the risks of problems increase with multiple daily injections when you aren’t rotating.
Jerry Meece, RPh, CDCES, FACA, FADCES: Early on, we thought that if you had a vial of insulin, you needed to put an ice chest in the back of your car, put the insulin in there, and carry it with you. Wherever [you were], you had all this ice and everything else. What have we learned from storage and handling of insulin? What are you telling patients about that?
Jennifer D. Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP: If they’re using pens, the one they’re using can remain at room temperature. The extra ones should be put in the refrigerator. We have ultra-long-acting basal insulins that can stay out of the refrigerator for 56 days. That was unheard of before. When someone goes on vacation, they might be able to bring 1 pen and no ice or ice packs. It’s important that they keep it with them. They don’t want to put it in their glove compartment or in the sun. [It has to be] room temperature. If they’re going to be traveling and they’ll be in a heated situation, they need to bring a little refrigerated bag with an ice pack. But storage is either 2 months for the newer ones or 28 days for the other ones. It’s the same thing with the vials. Keep extra ones in the refrigerator, and the one you’re using can stay out at room temperature for that month.
Jerry Meece, RPh, CDCES, FACA, FADCES: When someone is starting on insulin, how do you address the carbohydrate situation? What do you do in practice when someone says, “OK, I’m on insulin. What do I do with food?” How do you handle that?
Jennifer D. Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP: That’s such an important question that comes up all the time. Patients care about what they can eat. They think, “Now I have diabetes, and I can’t eat anything. What am I supposed to have?” Have that conversation about food choices, that you can eat just about anything because we can fix almost anything with insulin, but it’s all about choices. Make sure patients understand what a balanced meal is. Protein isn’t going to raise your blood sugars, but carbohydrates, such as muffins and doughnuts, are certainly going to raise your blood sugars higher than vegetables and fruits.
We need to help them understand balance, choosing the right foods, and portion control. We need some help from dietitians, if necessary, to refer them for more specific carb counting if they’re interested. Carb counting is important for people with type 1 diabetes. If you have someone with type 2 diabetes who wants to learn carb counting, that’s certainly something that they can do, and [you should] bring in the team for that.
Jerry Meece, RPh, CDCES, FACA, FADCES: It’s great to have a dietitian there. We’re part of a team, and [it’s helpful] for us to be able to refer to a dietitian and have them refer back to us. That multidisciplinary thing is what we’re all about, and it makes everybody sing from the same hymn book. We’re all on the same page in what we’re trying to tell this person. We certainly try to make our patients carb-aware. I sometimes put a couple of food samples on plates. As pharmacists, we need to talk with our patients about food when we’re talking about things like insulin. If our patients don’t know the difference between a carb and a carburetor, the insulin isn’t going to help them any. We need to make sure they know what’s going to bring blood glucose up, what’s going to leave it alone, and what a meal looks like when you’re injecting your insulin. I couldn’t agree with you more, Jennifer.
Transcript edited for clarity.