Pharmacists Are Key Allies in Reducing Risk of Diabetes, Cardiovascular Disease

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality, both globally and in individuals with type 2 diabetes (T2D).¹

Individuals with diabetes are at greater risk of developing cardiovascular disease (CVD), with common risk factors including high blood pressure (BP), abnormal cholesterol levels and high triglycerides, obesity, physical inactivity, poorly controlled blood sugars, and smoking. Pharmacists, as part of an interdisciplinary team, can play an important role in helping patients with prediabetes or diabetes reduce their risk of CVD through education, medications for risk reduction, and lifestyle modifications.

Prediabetes and Prevention of T2D

Approximately 88 million adults in the United States have prediabetes, which includes about 84% who do not realize they have it and are at risk of developing T2D and CVD.²

According to the American Diabetes Association (ADA), individuals who meet any 1 of the following criteria have prediabetes:

1. fasting plasma glucose of 100 mg/dL to 125 mg/dL,
2. 2-h plasma glucose during 75-g oral glucose tolerance test of 140 mg/dL to 199 mg/dL, or
3. glycated hemoglobin (A1C) of 5.7% to 6.4%.³

The ADA recommends annual monitoring for the development of T2D in patients with prediabetes.³ Pharmacists can also screen patients for risk of developing T2D during medication therapy management consults using the 60-second ADA risk test.⁴ This tool is available electronically and in print, and the results can be emailed to the patient. Individuals who score 5 or higher may have prediabetes, and these results along with lab work can serve as an important counseling and referral tool.⁴

Metformin pharmacotherapy for the prevention of T2D should be considered in patients with prediabetes, especially in the following individuals: body mass index greater than or equal to 35 kg/m2, individuals under 60 years of age, and women with prior gestational diabetes mellitus.³ Patients should have their vitamin B12 levels monitored because long-term metformin therapy may cause vitamin B12 deficiency.³ 

Patients with prediabetes should be referred to an intensive lifestyle behavior program known as the National Diabetes Prevention Program (DPP) to achieve and maintain a 7% loss of initial body weight and increase moderate intensity physical activity to at least 150 minutes each week.⁵ The National DPP was developed in 2010 by the CDC along with other organizations to prevent T2D in the United States, and patients must meet certain eligibility criteria to enroll (see Table).⁶ The 1-year lifestyle change program is one of the key components of the National DPP for patients to reduce risk of developing T2D, and it includes a CDC-approved curriculum (approximately 24 hours of instruction), a lifestyle coach, and support group.^5,7 Evidence has shown that the National DPP reduces the risk of developing T2D by up to 58% (71% for those over 60 years of age) in participants who lost 5% to 7% of their body weight and added 150 minutes of exercise per week.⁵   

Pharmacists can promote awareness about prediabetes and educate patients at risk about the National DPP.⁸ Additionally, evidence demonstrates that more pharmacy sites are offering the program.9 Administering a blood glucose test is a great way to identify patients with prediabetes and communicate this information to the primary care physician or refer individuals to a health care provider. Pharmacies can also deliver the National DPP by applying to become CDC recognized, and pharmacy residents, students, and technicians can help to support the program.⁸

Table. National Diabetes Prevention Program Eligibility Criteria⁶

• At least 18 years of age
• BMI > 25 or > 23 if Asian
• Not pregnant
• No previous diagnosis of type 1 or type 2 diabetes
• Prediabetes blood test results within the past year:
• A1C of 5.7% to 6.4% or,
• FPG of 100-125 mg/dL or
• 2-hour PG (after a 75-gm glucose load) of 140-199 mg/dL
• Previous clinical diagnosis of gestational diabetes or high risk for type 2 diabetes results from prediabetes risk test
• Medicare beneficiaries are required to have a blood test within the past year to qualify

A1C, glycated hemoglobin; BMI, body mass index; FPG, fasting plasma glucose; PG, plasma glucose.

CVD Risk Reduction Strategies

The American College of Cardiology (ACC) and American Heart Association (AHA) recommend a team-based approach for the prevention of CVD.¹

Adults should consume a healthy diet that includes vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish. Additionally, the diet should minimize the intake of trans fats, processed red meats, refined carbohydrates, and sweetened beverages.¹ Evidence demonstrates that dietary sodium consumption of less than 1500 mg/d and reduced alcohol intake (men ≤ 2 drinks daily and women ≤ 1 drink daily) are nonpharmacological ways to reduce BP.¹ Individualswho are overweight or obese should receive counseling on caloric restriction to reduce their risk of CVD. Adults should also engage in at least 150 minutes per week of moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.¹ Patients should also be assessed at every health care visit for tobacco use, and those who are smokers should receive smoking cessation support through a combination of behavioral interventions and pharmacotherapy (eg, nicotine replacement therapy).¹ 

Individuals aged 40 to 75 years being assessed for CVD should routinely undergo the 10-year risk of ASCVD, and adults aged 20 to 39 years should be assessed every 4 to 6 years.¹ The ASCVD risk estimator is available as a free app that health care professionals can use at the point of care to help guide clinical decisions.¹⁰ The 10-year risk for ASCVD is categorized as the following: low risk, less than 5%; borderline risk, 5% to 7.4%; intermediate risk, 7.5% to 19.9%; high risk, greater than or equal to 20%.¹⁰ Most adults with diabetes have a 10-year ASCVD risk of greater than or equal to 10%.

Statin therapy is considered first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥ 190 mg/dL), those with diabetes, individuals aged 40 to 75 years , and those determined to have a sufficient ASCVD risk.¹ The ACC/AHA guidelines discuss that aspirin should not be routinely used for the primary prevention of ASCVD in adults at any age who are at increased risk of bleeding.¹ Also, low-dose aspirin should not be given for the primary prevention of ASCVD in adults 70 years and older. Low-dose aspirin may be considered for the primary prevention of ASCVD among certain adults aged 40 to 70 years who are at higher risk of ASCVD but not at increased risk of bleeding.¹ Pharmacists can play an important role in counseling patients and educating other health care professionals about these new aspirin recommendations.

The ADA recommends that patients with diabetes have individualized BP goals.¹¹ If individuals with diabetes and hypertension are at higher risk of ASCVD or have a 10-year ASCVD risk greater than or equal to 15%, then a target BP of less than 130/80 mm Hg may be appropriate. Patients at lower risk for CVD (10-year ASCVD risk < 15%) should receive antihypertensive treatment to a target BP of less than 140/90 mmHg.¹³ Evidence demonstrates that angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, thiazidelike diuretics, and dihydropyridine calcium channel blockers can all reduce cardiovascular events in patients with diabetes, and any of these drug classes can be utilized as initial treatment for hypertension .¹¹ 

The Community Preventive Services Task Force recommends tailored pharmacy-based interventions to enhance adherence in patients with CVD risk factors.¹² Evidence demonstrates that pharmacist interventions in the community and hospital settings increase medication adherence through pill boxes, medication cards, calendars, medication refill synchronization, and follow-up.¹² Additionally, improved medication adherence results in health care cost savings.¹² Pharmacists can communicate interventions with the patient’s primary care provider as an interdisciplinary approach to CVD prevention.

References

1. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation. 2019;140(11):e596-e646. doi:10.1161/CIR.0000000000000678
2. Prediabetes — your chance to prevent type 2 diabetes. CDC. Last reviewed June 11, 2020. Accessed December 28, 2020. https://www.cdc.gov/diabetes/basics/prediabetes.htm  
3. American Diabetes Association. 3. Prevention or delay of type 2 diabetes: Standards of Medical Care in Diabetes—2021. Diabetes Care. 2021;44(suppl 1):S34-S39.
   doi:10.2337/dc21-S003 
4. Our 60-second type 2 diabetes risk test. American Diabetes Association. Accessed December 28, 2020. https://www.diabetes.org/risk-test
5. National Diabetes Prevention Program: information for health care professionals. CDC. Last reviewed March 5, 2019. Accessed December 28, 2020. https://www.cdc.gov/diabetes/prevention/info-hcp.html
6. National Diabetes Prevention Program: program eligibility. CDC. Last reviewed March 5, 2019. Accessed December 28, 2020. https://www.cdc.gov/diabetes/prevention/program-eligibility.html
7. Recognized lifestyle change program. CDC. Accessed December 28, 2020. https://nccd.cdc.gov/DDT_DPRP/Programs.aspx
8. Rx for the National Diabetes Prevention Program: action guide for community pharmacists. CDC. Revised July 2019. Accessed December 29, 2020. https://www.cdc.gov/diabetes/prevention/pdf/pharmacists-guide.pdf
9. Ross LW, Bana F, Blacher RJ, et al. Continuous stakeholder engagement: expanding the role of pharmacists in prevention of type 2 diabetes through the National Diabetes Prevention Program. Prev Chronic Dis. 2020;17:E41. doi:10.5888/pcd17.190374
10. ASCVD risk estimator plus. American College of Cardiology. Accessed January 1, 2021. http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
11. American Diabetes Association. 10. Cardiovascular disease and risk management: Standards of Medical Care in Diabetes—2021. Diabetes Care. 2021;44(suppl 1):S125-S150. doi:10.2337/dc21-S010
12. Cardiovascular disease: tailored pharmacy-based interventions to improve medication adherence. Community Preventive Services Task Force. Updated July 28, 2020. Accessed January 1, 2021.