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Three take-aways pharmacists and other retail clinicians can use in their practice today
June 2015, Vol 3, No 6 - Inside Pharmacy
Samantha Yovanoff, PharmD

Every January the American Diabetes Association (ADA) publishes the Standards of Medical Care in Diabetes.1

This publication includes guidelines for the diagnosis and treatment of diabetes, management of diabetes-related complications, and management of diabetes in special populations, as well as ways to advocate for the disease.

The standards that were published in January 2015 included several updates that align with other treatment guidelines and changes based on results of several studies and expert opinion. Some of these updates can have an impact on pharmacy practice and the way pharmacists provide care to their patients.

1. Reassessing Blood Pressure Goals

The first major update to the standards was the change in blood pressure goals for patients with diabetes.

The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults, published by the Eighth Joint National Committee, set the blood pressure goals for patients aged ≥18 years as <140/90 mm Hg.2 Based on several randomized trials, the ADA followed suit and also updated their goals from <130/80 mm Hg in 2013 to <140/90 mm Hg in 2014.3,4

The ADA recommendation (Grade A) was based on several randomized controlled trials, including the results of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, which indicated no benefit of lowering systolic blood pressure to <120 mmHg, compared with <140 mm Hg.5

For pharmacists, taking blood pressure readings is common practice. Patients often come in to have their blood pressure checked on the monitor, or by the pharmacist between physician visits. These recommendations will allow us as pharmacists to better counsel patients on their blood pressure numbers, make suggestions to guide lifestyle changes, or refer them to their physician to discuss changes in blood pressure or additions to their medication regimen.

2. Preprandial Glucose Range

The ADA guidelines also included updated recommendations regarding the blood glucose range goal for preprandial glucose. The new minimum goal is 80 mg/dL, versus 70 mg/dL in the previous guidelines4; the upper range remains 130 mg/dL.

The minimum range was raised to better meet the average blood glucose levels, which reflect A1c levels.4 It is recommended that A1c levels be checked at least twice a year because they can give physicians a broader perspective on the patient’s glucose control.1 For example, an A1c of 7%, which the ADA recommends as a reasonable A1c goal, correlates to an average plasma glucose level of 154 mg/dL and a mean preprandial glucose level of 152 mg/dL.6 These numbers fall above the ADA’s recommended goal range of <7% (which is still considered good), although recent guidelines suggest that treatment goals be individualized based on age, comorbidities, and disease duration.6

In addition to providing A1c testing, pharmacists can help patients keep track of their goals and blood glucose levels, as well as provide information about symptoms such as hyperglycemia and hypoglycemia.

3. Pneumococcal Immunization

A more recent task that has been integrated into pharmacists’ workflows is administering immunizations. Most major retail pharmacies now offer pharmacist-administered vaccines, where patients can either walk in or make an appointment to get a variety of vaccinations (eg, annual flu and shingles shots, and specific travel immunizations).

In particular, the ADA guidelines recommend that patients with diabetes receive the pneumococcal vaccine, but until 2015 the guidelines never specified which pneumococcal vaccine. The guidelines have been updated to reflect the Centers for Disease Control and Prevention immunization schedule, and now recommends that all patients aged ≥2 years with diabetes get the pneumococcal polysaccharide vaccine 23 (PPSV23).1 Adults aged ≥65 years who have not received any pneumococcal vaccines should first get the pneumococcal conjugate vaccine 13 (PCV13), followed by PPSV23 after 6 to 12 months. Patients aged ≥65 years who have already received PPSV23 should receive the PCV13 after ≥12 months.

Although, to my knowledge, no major studies have shown increased rates of morbidity or mortality in patients with diabetes and influenza, observational studies have shown increased rates of hospital admissions, hospitalizations, and complications in this patient population.7

Conclusion

The role of the pharmacist is ever expanding to include increased patient counseling and clinical services. As the most accessible healthcare provider in the community, our role in patient care is crucial.

Most patients go to the pharmacy much more often than they go to their primary care physician’s office, which gives us an opportunity to take action on our patients’ health. The updates that are discussed in this article include 3 ways that pharmacists can have an impact on patient care.

Working in a retail pharmacy, I often see people check their blood pressure on the machine located just outside the pharmacy. Quite often, these machines are not calibrated correctly and give patients a surprising blood pressure reading. By manually checking patients’ blood pressure, we have the chance to counsel and answer any other questions they may have.

It is important that pharmacists stay up-to-date on all emerging guidelines, but because diabetes encompasses many other disease states and disease-related complications, I urge all practicing pharmacists to familiarize themselves with the 2015 Standards of Medical Care in Diabetes, and to continue to read the yearly updates published every January.




References

  1. American Diabetes Association. Standards of medical care in diabetes—2015. Diabetes Care. 2015;38(Suppl 1):S14-S80.
  2. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507-520.
  3. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(Suppl 1):S11-S66.
  4. Standards of medical care in diabetes—2015: summary of revisions. Diabetes Care. 2015;38(Suppl 1):S4.
  5. Cushman WC, Evans GW, Byington RP, et al; ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575-1585.
  6. Wei N, Zheng H, Nathan DM. Empirically establishing blood glucose targets to achieve HbA1c goals. Diabetes Care. 2014;37:1048-1051.
  7. Smith SA, Poland GA. Use of influenza and pneumococcal vaccines in people with diabetes. Diabetes Care. 2000;23:95-108.
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