Nontraditional or noncentralized models of diabetes care: Medication therapy management services

The Journal of Family Practice. 2011 November;60(11):S12-S18

November 1, 2011|Family Medicine

TABLE 3

Case study: Health problems and medications at the time of medication therapy review

Health problems	Medications	Recommendations
Type 2 diabetes	Insulin detemir 40 U qAM and 60 U qhs; then titrate appropriately if necessary Insulin aspart according to advanced carbohydrate counting technique	Titrate basal insulin as necessary. Continue self-monitoring of blood glucose 3 or more times a day. Patient’s blood glucose still spikes even with continued carbohydrate counting for each meal. Stress the importance of eating 3 meals a day. Patient should be educated on signs of hypoglycemia because her beta-blocker may enhance the hypoglycemic effect of insulin.
Hyperlipidemia	Statin (temporarily discontinued to investigate muscle cramps) Prescription omega-3 fatty acids (noncompliant because of large capsule size)	Consider ruling out other causes of muscle symptoms and of creatine kinase elevation. Evaluate possible statin drug-drug interaction with other medications that patient in currently using. Restart appropriate statin therapy after evaluation is completed. Start fenofibric acid delayed-release to reduce hypertriglyceridemia if triglyceride levels are still elevated on statin therapy. Switch to smaller, over-the-counter omega-3 capsules.
Hypertension (poorly controlled)	Angiotensin II receptor antagonist Beta-blocker	Maintain current angiotensin II receptor antagonist. Consider switching from twice-daily to once-daily formulation of beta-blocker to increase adherence. Stress importance of exercise and of following the low-salt DASH diet. Consider adding a third medication if blood pressure is not in control after the above interventions.
Cardiovascular disease	Low-dose aspirin	Consider evaluating patient for the diagnosis of congestive heart failure.
Gout	—	Measure uric acid levels. Start allopurinol 100 mg once daily if uric acid level is high, and check uric acid levels periodically for dose adjustments. Advise avoidance of purine-rich foods such as organ meat.
GERD	Proton pump inhibitor	Maintain current therapy. Advise avoidance of foods that exacerbate or induce GERD.
Obesity	—	Consider cortisol testing as patient shows signs of Cushing’s syndrome. Advise on exercise and dietary changes to promote weight loss.
Seasonal allergies	H₁-receptor blocker	Maintain current therapy as necessary during allergy season.
DASH, Dietary Approaches to Stop Hypertension; GERD, gastroesophageal reflux disease.

Clinical and economic outcomes of MTM

As MTM programs are too diverse to be studied as a group, most outcome studies conducted to date provide data only on specific MTM programs and provide little information about MTMs overall.¹⁵ Furthermore, few, if any, studies have examined the effects of MTMs specifically in diabetes. However, numerous publications suggest that pharmacist-provided care can improve clinical outcomes. According to 2 systematic reviews of studies conducted in patients with diabetes, A1C was highly sensitive to a variety of interventions by pharmacists, such as diabetes education and medication management.^31,32 In a Veterans Affairs Health Care System, pharmacists’ use of a preplanned insulin initiation and titration protocol resulted in the successful implementation of an insulin initiation clinic through CDTM and improved patients’ glycemic control compared with when the patients were receiving only oral antihyperglycemic agents.³³ Two often-cited programs, the Asheville Project³⁴ and the Diabetes Ten City Challenge,³⁵ demonstrated that pharmacist-provided MTM-like care for T2DM resulted in health care cost savings, as well as improved clinical outcomes. However, these results are not directly applicable to MTM services because they were conducted in relatively healthy employee populations. Many studies have examined the overall effects of MTMs on health care costs, but results have been inconsistent, in part because of variation in which costs were included in the analyses.²⁰ It seems inevitable that as the MTM model matures, data will demonstrate the clinical and economic value of pharmacists providing primary care for patients with T2DM and other complex medical conditions.

Conclusions

Pharmacists can help optimize diabetes drug therapy by improving tolerability, reducing risks, and increasing patients’ likelihood of attaining treatment goals. Pharmacist-led diabetes education can go beyond medication and glycemic control to promote overall wellness and a healthy lifestyle. With their involvement in MTM, pharmacists can apply their expertise in drug therapy to a patient population with complex and challenging needs.

References