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Heather Folz, PharmD, BCACP and Christina H. Sherrill, PharmD, BCACP, BC-ADM discuss challenges pharmacists may face when implementing CGM services and how they can help raise awareness.

Q&A: Pharmacists Can Help Raise Awareness About CGMs

A conversation with Heather Folz, PharmD, BCACP and Christina H. Sherrill, PharmD, BCACP, BC-ADM.

Challenges Pharmacists May Face When Implementing CGM Counseling

Heather Folz, PharmD, BCACP and Christina H. Sherrill, PharmD, BCACP, BC-ADM, discuss a recent study that examined how wearing a continuous glucose monitor impacts student pharmacists.

Hands-On CGM Training Helps Student Pharmacists Prepare for Career

journal explores issues within pharmacy, from the impact advocacy can have in community pharmacies to staffing shortages across multiple sectors within pharmacy. This month’s issue also explored the importance of disease awareness months and how they are opportunities to maximize valued care. Check out a preview of this month’s issue here.

download the PDF of the Total Pharmacy August 2024 issue here

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See what’s trending in pharmacy with a preview of the Total Pharmacy August issue.

Total Pharmacy

In This Issue: Total Pharmacy August 2024

Combining sodium glucose co-transporter 2 inhibitors (SGLT2is) with glucagon-like peptide-1 receptor agonists (GLP-1RAs) may offer additional protection against cardiovascular and kidney disease in patients with type 2 diabetes (T2D), according to the results of a new meta-analysis published in 

 and presented at the 61st European Renal Association Congress in Stockholm, Sweden.

Separately, SGLT2is and GLP-1RAs have demonstrated cardiovascular benefits. However, little clinical literature has focused on outcomes associated with using the medicines together. Due to the growing prevalence of GLP-1RAs in the 

 and obesity landscape, accelerated by an increasing number of indications for the agent class, this is a crucial area for further study.

The SGLT2 Inhibitor Meta-analysis Cardio-Renal Trialists’ Consortium (SMART-C) is the largest assessment of outcomes for the combined therapeutic use of SGLT2is and GLP-1RAs. The study gathered data from 12 large-scale, placebo-controlled trials of SGLT2is involving 73,238 patients with diabetes. Of these, 3065 were already receiving GLP-1RAs.

Overall, SGLT2is lowered the risk of major adverse cardiovascular events by 11% and hospitalization for heart failure or cardiovascular death by 23% compared to placebo. Notably, this benefit was seen regardless of whether patients were also taking GLP-1RAs.

When used together with GLP-1RAs, SGLT2is reduced the risk of chronic kidney disease progression by 33% and slowed the annual loss of kidney function by nearly 60%.

The study found no additional safety concerns when SGLT2is were used in combination with GLP-1RAs.

Study Reveals Robust Benefits of Semaglutide in Protecting Against Kidney, CV Events in Patients With T2D

Current meta-analysis results build off positive results of the landmark FLOW trial (

). Published earlier in May, results of the international, double-blind, randomized, placebo-controlled phase 3 trial spotlighted semaglutide’s effectiveness in lowering the risk of kidney failure, decelerating worsening kidney function, and protecting against the risk of cardiovascular events and death, in patients with T2D.

“SGLT2 inhibitors have clear protective effects against heart failure and chronic kidney disease, while GLP-1 receptor agonists can reduce the risk of heart attack, stroke, and also kidney disease—as recently demonstrated in the landmark FLOW trial,” said Brendon Neuen, lead author, clinical associate professor, senior research fellow at The George Institute for Global Health, and director of kidney trials at Sydney’s Royal North Shore Hospital, in a news release.

 “Our findings support using this combination to further improve outcomes in patients with type 2 diabetes who meet guideline recommendations for both therapies.”

Elevated glucose from diabetes can damage blood vessels in the heart and kidneys, increasing the risk of 

 and kidney disease. In fact, diabetes is the most common cause of chronic kidney disease.

Moreover, estimates predicting that T2D prevalence will more than double in the next 30 years, surpassing 1 billion global cases by 2050, further strengthen the need for research into diabetes care.

 According to Neuen in an interview with 

 conducted over email, the current study offers valuable insights for developing global treatment strategies for the condition.

"These findings, which represent the largest and most comprehensive evaluation of the combined use of SGLT2i and GLP-1RA, provides the clearest evidence yet that combined use of both medicines can further reduce cardiovascular and kidney disease," said Neuen. "We anticipate that these findings will inform how people with diabetes are treated worldwide, including influencing major clinical practice guidelines.

Although current results suggest that using SGLT2is and GLP-1RAs in tandem may offer robust protection against cardiovascular and kidney disease, further research is needed to fully understand the long-term effects of the combination therapy.

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1. Apperloo E, Neuen BL et al. Efficacy and safety of sodium glucose co-transporter 2 inhibitors with and without glucagon-like peptide-1 receptor agonists: A SMART-C collaborative meta-analysis of randomised controlled trials. 

. 2024. doi: 10.1016/S2213-8587(24)00183-9

2. Massaro L. Study reveals robust benefits of semaglutide in protecting against kidney, CV events in patients with T2D. 

https://www.drugtopics.com/view/study-reveals-robust-benefits-of-semaglutide-in-protecting-against-kidney-cv-events-in-patients-with-t2d

3. Combining popular diabetes drugs offers complementary heart and kidney benefits. News release. The George Institute for Global Health. July 9, 2024. Accessed July 10, 2024. 

https://www.georgeinstitute.org/media-releases/combining-popular-diabetes-drugs-offers-complementary-heart-and-kidney-benefits

4. Mayo Clinic Staff. Chronic kidney disease. Fact sheet. Accessed July 8, 2024. 

https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-20354521

5. Klein HE. Diabetes prevalence expected to double globally by 2050. 

https://www.ajmc.com/view/diabetes-prevalence-expected-to-double-globally-by-2050

When used together, sodium glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) were able to lower the risk of major adverse cardiovascular events and kidney disease by 11% and 33%, respectively.

Clinical

SGLT2i, GLP-1RA Combination Therapy Offers Robust Protection Against Cardiovascular, Kidney Disease

As pharmacists are experts in medication and possess the social skills to build successful health management plans for their patients, they too are uniquely positioned to guide patients on weight-loss journeys and lifestyle changes designed to improve health. The perfect example of a health care provider moving into both the pharmaceutical and nutritional spaces is Sarah Gray, PharmD, GAICD, known to her patients and followers as “The Nutrition Pharmacist.”

“Before people start to eliminate food groups or go on a keto or a carnivore diet—or all these new diets that come up that won't exist in 10 years’ time because they just keep cycling around—I think they really just need to take care and think about who they're getting that information from,” Gray told 

. A pharmacist is “not just the white-coat person behind the counter labeling the boxes. We actually come out, we speak to people, and we can do a lot more for you.”

In part 3 of our interview with Gray, she focused on the capabilities of pharmacists to expand their scopes within the nutritional space, but also in health care overall. From her perspective as a pharmacist-turned-nutritionist in Melbourne, Australia, to issues in access to obesity management services, Gray touched on several different areas of her expertise.

Stay tuned for a full-length podcast version of our discussion with Gray on the next installment of 

Q&A: A Pharmacist’s Career Journey to Becoming a Nutritionist

: To whom or where would a patient typically go if they were seeking nutritional counseling? In other words, prior to you offering your services and advancements in technology and the internet, where would people typically go for nutritional advice?

In an ideal world, they would be speaking to a qualified nutrition professional. I think that's a pretty common thing. People would usually go to speak to a doctor or somebody about their health and typically be steered to speak to a qualified nutritionist or dietitian. I do actually really like that the eat right website has a great 

 function from the Academy of Nutrition and Dietetics. You can actually find someone that's qualified. Sometimes when you do go to seek a nutrition professional, unfortunately, it can be a rather poorly regulated industry across the world in that you may be able to do a really quick 3-week course on nutrition and then label yourself as a nutritionist.

The other place that people look to, if you think about human nature, you just go to other people, don't you? So, if you want to lose weight, or if you want to gain muscle, or you're starting a new healthy lifestyle, you ask your friends and family, which can be great but also can be a challenge because what works for them may not always work for you. Then we look at, in this day and age [of] what people could be doing, I think there's so many more opportunities. Whereas before, people were asking family and friends, now there's the internet, you can just search and ask Dr. Google, or find solutions on social media. It's huge in this space. If people want to lose [weight], they want to look like that influencer [and] they'll follow whatever that influencer did.

But before people start to eliminate food groups or go on a keto or a carnivore diet—or all these new diets that come up that won't exist in 10 years’ time because they just keep cycling around—I think they really just need to take care and think about who they're getting that information from. Then, they can use the tools that they find. They might be health-tracking tools or smart watches that might help support them now, which you wouldn't have had many years ago. So, there's lots of options, which I actually think makes it harder. Whereas before, you would have just been told by your doctor, “Hey, go speak to a dietitian.” Now you've got all these options, and you really can self-direct it without knowing if what you're doing is the best for you from an evidence-based perspective.

: Obviously, with your background as a pharmacist eventually becoming a nutritionist, it's safe to say that you fully support pharmacists branching out as nutritionists. What is it about pharmacists that make them stand out amongst other health care providers when it comes to offering nutrition advice and counseling?

To me, the combination of pharmacy and nutrition is a match made in heaven. I actually hope it becomes a really, much more popular path. There are not a lot of people that combine the 2, but more and more, I get people asking me questions through social media or email or in day-to-day life about how can I do this and how have you found it useful? So, I'm glad that we're talking about it. For me, pharmacists have such great skills across many areas. I think the key [area] I've found that really matches well with nutrition is our great patient-interviewing skills and being able to really consider all factors of a patient's life, so what medications they're taking, what medical conditions, what symptoms they have.

Now, adding the nutrition side, I can get a really good picture of all the areas of the person's health. We're really good at doing that in a quick way. So, [if] we've got somebody in front of us in the pharmacy, we're really good at asking lots of different questions to find out the problem in a fast way and helping people quickly. Having that investigative skill is really great. The other thing is our science background. It gives us an added edge when it comes to things like understanding nutritional supplements. We're not just thinking about the nutrient, but we're thinking about how they process in the body, how will they interact with other medications, and things that, if you don't have that background, you're not thinking about as a nutritionist. I found, actually, the supplement side of things has become quite a big part of what I do. Not that I think they are the be all and end all, but [it’s] actually fully understanding those depletions that drugs might cause—drug interactions, drug-nutrient interactions, even drug-food and diet interactions.

I think it's a great opportunity to add in some nutritional advice, education, and giving appropriate supplements. I think the good thing is we can do it at a mass level. When you think about it in a community pharmacy and other pharmacy settings, the amount of people we speak to every single day, if we just add a little bit of nutritional advice to each of those people, we can have a much bigger public health impact than people that go and visit a nutritionist, which is a much smaller percentage. I think that's one of the other great benefits also.

: When it comes to pharmacists in in the nutritional space, or in health care in general, what are your overall hopes for the profession going forward?

My hope is that more people can see the pharmacist for all of their glory. What a wonderful profession we are. We're across every bodily area, every system, all the medications, everything we need to help a person. I call us “specialist generalists.” We're not in detail, granular about every single thing, but we have a broad area. How many professions can you ask a question about headaches, or about diabetes, or about weight-loss, and you actually will get a very decent answer and some sort of recommendation? Obviously a doctor can do that, but I'm talking in the sense of an allied health professional that's really accessible for people. We really undervalue ourselves, I think, as a profession. In Australia more so, I'm probably leaning on that reflection, but I think we are such a great profession.

I have the hope that we see pharmacists valuing themselves more and then adding more strings to their bow, so that we can shine in the key pillar of the health profession. We're not just the white-coat person behind the counter labeling the boxes. We actually come out, we speak to people, and we can do a lot more for you. I hope that people find different parts of their areas that can add together. Can you add exercise? Can you become a physiotherapist and a pharmacist? I have friends who have done that. That's amazing, because as a physiotherapist, you're recommending anti-inflammatories and medication, and you understand more about that. Don't be afraid to add things in that might seem a bit strange, but also, as a pharmacist itself, you don't need anything else, really. You can offer so much to people as a profession.

Q&A: Nutritional Pharmacist's Perspective on New Year Dieting Trends

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Sarah Gray, PharmD, GAICD, explored the unique combination of being both a pharmacist and nutritionist.

Q&A: The Pharmacist’s Ability to Provide Nutritional Guidance

With biosimilar medications standing out as a cost-effective option for brand-name prescription drugs, they have garnered speculation among both patients and providers regarding efficacy and safety. Coupled with their recent introduction into the pharmaceutical space, experts believe education on these newly adopted medications is key to improving patient outcomes.

“Educating patients and making sure that we address their concerns is key,” Amanuel Kehasse, PharmD, PhD, Director of Clinical Programs and Drug information at Clearway Health in Boston. “Providers [are] the same. A lot of providers have concerns to use biosimilars, especially for the non-medical switch. Educating providers why this will be important clinically and financially for the health care system would be key.”

Check out Kehasse’s exclusive interview with 

, discussing the common barriers providers face when looking to encourage the use of biosimilars and how pharmacists will be able to maneuver these issues going into 2025.

: What are the key barriers to biosimilar implementation and how can those barriers be addressed?

There are several barriers to biosimilar implementation to clinical practice. The first is the perception or knowledge gap that exists in providers and patients themselves. Speaking of the patients, they are the final step of biosimilar conversion and implementation and they are the ultimate users of this medication. We know from [a] survey stance, so far, there is a gap in their knowledge about biosimilars. Some of them do not understand what [a] biosimilar is. Some of them may think this is an inferior medication because they always hear the lower cost. So, this is for us to educate: Always, health care should be a cost-effective care provision without compromising the safety and efficacy of the medication. Biosimilars give us that alternative cost-effective care to reference products, so [it’s] educating them that the lower cost does not mean the biosimilar is inferior. We can also share some real-world evidence to show patient experience after the transition to biosimilar. What happened? Are they happy with it clinically? How did they do? That's when the real-world evidence data comes to play to make sure that patients are comfortable to switch. Educating patients and making sure that we address their concerns is key. Providers [are] the same. A lot of providers have concerns to use biosimilars, especially for the non-medical switch. Educating providers why this will be important clinically and financially for the health care system would be key.

The other one is system barriers. Health systems need to make sure that they build the infrastructure to adopt biosimilars. It's a blessing in disguise for operational complexity in pharmacies. When you have multiple biosimilars coming to the market, then you have to have inventory that will have to [be addressed] efficiently. It opens up for errors, so they have to build infrastructure [on] how to manage multiple [inventories] for multiple biosimilars. Pharmacists need to be sure that they are using the right medication and [electronic medical records] (EMR) for physicians to make it easier to prescribe biosimilars. You have to build the structure and [EMR] to make sure that the ease of ordering is put in place, because you don't want them to struggle to find which medication will be appropriate to them. Formulary decisions [are] also important. Not only insurance but health systems have to put this medication in their formulary so that acquisition will be easier. A third is the pair themselves. So once biosimilars are coming to the market—we've seen back in 2020, 2021, up to 2023—there was a significant delay in adoption of biosimilars. Part of that has to do with the patent litigation of manufacturers, but part of that has to do with the pairs; not adapting these biosimilars into their formulary. Or even if they do, they make [it] non-preferred. All these things will delay or impede the adoption of biosimilars into the market.

2024 ASHP Midyear Clinical Meeting and Exhibition here

Drug Topics met with Amanuel Kehasse, PharmD, PhD, to discuss the barriers surrounding biosimilar implementation in the prescription drug market.

Health System

Q&A: Educating Patients, Providers to Increase Biosimilar Implementation | ASHP Midyear

Over 38 million adults in the United States have diabetes and an estimated 97.6 million have pre-diabetes.

 By the year 2030, the prevalence of diabetes is expected to increase significantly, with research estimating that more than 54 million Americans will have the condition.

 Continuous glucose monitors (CGM) have been shown to improve HbA1c, time in target range, and minimize time below range in patients with diabetes. Although the use of CGMs has increased substantially since their introduction, several barriers remain that inhibit their adoption.

At the American Society of Health-System Pharmacists 2024 Midyear Clinical Meeting and Exhibition, held December 8 to 12 in New Orleans, Louisiana, 2 posters presented at the meeting looked deeper into the topic of CGMs, comparing the devices to traditional glucose monitoring and examining the impact of a pharmacist driven CGM education service within primary care.

SGLT2 Inhibitors May Have Clinical Benefits For Patients with Diabetes After Myocardial Infarction | ASHP Midyear

In the first poster, investigators from Ascension Saint Francis conducted a study to examine the impact of CGM on diabetes outcomes for patients who are managed by an ambulatory care pharmacist.

 The multi-center, randomized, retrospective chart review collected data from 4 pharmacist-run pharmacotherapy clinics in Chicago, Illinois and compared 2 groups of patients: patients using CGM and those using traditional glucose monitors.

The study cohort included 44 adult patients with diabetes who had at least 2 clinic visits between HbA1c draws, follow-up HbA1c at least 2 months from their initial visit, and follow-up HbA1c less than 6 months from their initial HbA1c draw. For patients using CGM, additional inclusion criteria included having been using CGM for at least 2 months and having access to CGM reports. The primary study endpoint was the percent change in HbA1c from baseline clinic enrollment or CGM initiation to first follow-up HbA1c.

The study found that the mean percent change in HbA1c from baseline to the first follow-up was -1.07% for the CGM group and -1.94% for the traditional glucose monitor group over a 4 month average. Only small changes were seen between baseline and the first follow-up for the average time in range, average time below range, average blood glucose and average coefficient of variation for the CGM group. Additionally, 2 patients in the CGM group visited an emergency department or were hospitalized, compared to 1 in the traditional group.

“The use of CGM devices did not improve diabetes outcomes when compared to traditional glucose monitors for patients managed by a pharmacist-run clinic,” the authors concluded. “Traditional glucose monitors were associated with numerically better improvements in hemoglobin HbA1c compared to CGMs. The largest improvements in hemoglobin HbA1c for the CGM group was observed in patients initiated on a CGM device within 3-6 months of pharmacotherapy clinic enrollment.”

In the second poster, investigators from Nebraska Medicine conducted a study to assess a pharmacist-led CGM education service within a patient-centered medical home primary care clinic.

 For the study, a workgroup of ambulatory care pharmacists, who were led by a post-graduate year 2 ambulatory care pharmacy resident, implemented device-specific education sessions and provided resources to standardize CGM education on common devices that are available commercially.

The program’s educational sessions focused on CGM device use, troubleshooting, set-up, and patient education. Additionally, an order panel was created to help improve access to CGMs, and make it easier for providers to order CGM devices and referral for pharmacist education.

From May 2023 to May 2024, 216 CGM education session had been conducted by pharmacists at the medical home. The program has improved CGM education and CGM data access, and has also increased provider education and overall patient access. The authors said that the next focus of the program will be “to create a standardized form for CGM ambulatory glucose profile data reporting and pharmacist outreach tracking.”

1. National Diabetes Statistics Report. Report. CDC. May 15, 2024. Accessed November 14, 2024. 

https://www.cdc.gov/diabetes/php/data-research/index.html

Two posters presented at the meeting looked into the topic CGMs in diabetes care.

Heather Folz, PharmD, BCACP

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