Treating the comorbidities of diabetes: The pharmacist's role


Diabetes is not one disease, but many. "We're beginning to talk about diabetes not as a single disease at all but as a metabolic syndrome," said Larry Ellingson, R.Ph., chair of the American Diabetes Association (ADA) in Alexandria, Va. "It's a cardiovascular disorder, a kidney disorder, and more, with potentially devastating effects on almost every organ." Pharmacists have a very important role to play in helping diabetes patients successfully cope with these potentially devastating effects, according to Ellingson and others.

"We are in the best position to look across a patient's treatment chart and see what medications are being taken and what medications should be considered for patients," noted Ellingson, who is also a member of the American Pharmacists Association. "We interact with patients more frequently than doctors and are highly trusted."

The first step is for pharmacists themselves to be aware of the wide range of comorbidities associated with diabetes. They affect many parts of the body and-if left untreated or are undertreated-often lead to serious complications such as blindness, kidney damage, and lower-limb amputations. Most people with diabetes die from cardiovascular conditions exacerbated by the disease.

Because so many diabetes patients see only primary care physicians and not specialists such as endocrinologists, pharmacists may find themselves taking up the slack. "Family practitioners on the average see their patients for 10 minutes at a time, and too often people with chronic diseases fall through the cracks," said Campbell. "Pharmacists should be very aware of the standards of care the proper treatment of diabetes requires, and they should discuss those standards with their patients."

Health-system as well as community pharmacists can and should play an important role in diabetes treatment, said Campbell. "We have found that tight glycemic control in inpatients can greatly reduce treatment complications and improve outcomes," he asserted. "Patients should be carefully monitored, and pharmacists need to be part of that process."

Research demonstrates that improving glycemic control through proper use of these medications or insulin, as well as proper diet and exercise-behaviors R.Ph.s who communicate with patients can encourage-benefits people with either Type 1 or Type 2 diabetes. The numbers are dramatic: For every 1% reduction in results of A1c blood tests (e.g., from 8.0% to 7.0%), the risk of developing microvascular diabetic complications (eye, kidney, and nerve disease) is reduced by 40%, according to the Centers for Disease Control & Prevention.

"Those kinds of numbers are what pharmacists should be talking to patients about," said Campbell, who has had diabetes for 55 years. "They see them five times more often than do their other providers. They have the opportunity to observe their patients and to begin a dialogue."

For example, pharmacists should be asking their patients whether they've recently had their blood pressure checked, say experts. Blood pressure control can reduce cardiovascular disease, such as heart disease and stroke, by 33% to 50% and can reduce microvascular disease, such as eye, kidney, and nerve damage, by about 33%, according to CDC. In fact, for every 10 millimeters of mercury (mm Hg) reduction in systolic blood pressure, the risk for any complication related to diabetes is reduced by 12%. Detecting and treating early diabetic kidney disease by lowering blood pressure can reduce the decline in kidney function by 30% to 70%.

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