Community pharmacists take on prediabetes

The great rise in the number of people with diabetes is matched by a rise in the prevalence of prediabetes. The Centers for Disease Control and Prevention (CDC) estimates that in 2012, 86 million American adults had prediabetes, or approximately 37% of the adults in America.¹

Prediabetes puts a person at greater risk for cardiovascular disease (CVD) and stroke, but the biggest risk is for type 2 diabetes (T2DM). According to the American Diabetes Association (ADA), people almost always pass through prediabetes on the way to developing T2DM.²

This epidemic is a silent one. Almost 90% of those who have prediabetes are unaware of their condition. The economic burden is large, however. The ADA cites data showing that over a five-year period starting in 2007, the cost of prediabetes rose to $44 billion, which is up 74%.³

Prediabetes defined

According to the ADA, prediabetes is characterized by an HbA1c of between 5.7% and 6.4%, a fasting blood glucose or plasma glucose levels of between 100 mg/dL to 125 mg/dL, and an oral glucose tolerance test of between 140 mg/dL and 199 mg/dL.²

See also: CPE: 2015 updates on the national guidelines for diabetes management and related disorders

Jerry MeeceTesting for prediabetes should include testing HbA1c and fasting plasma glucose, or plasma glucose levels two hours after an oral glucose-tolerance test. Children and teenagers who are overweight or obese and who have two or more risk factors for T2DM should be tested to see whether they are prediabetic.⁴

Upon hearing the term “prediabetes,” diagnosed patients may conclude that they are not sick yet, said Jerry Meece, RPh, CDE, FAADE. Meece is director of Clinical Services at Plaza Pharmacy and Wellness Center in Gainesville, Texas. “But prediabetes is still an illness. The pancreas is not working properly.”

“I don’t like to use the term prediabetes or prediabetic,” said Jonathan G. Marquess, PharmD, CDE, FAPhA, owner of 10 pharmacies in Georgia. “I prefer the term ‘impaired fasting glucose.’”

Bang for the buck

The ADA recommends strategies for use with people who have prediabetes, including annual monitoring, which in turn includes screening for modifiable risk factors for CVD, such as obesity, hypertension, and dyslipidemia.

See also: Type 2 diabetes: Better choices change the odds

People with impaired glucose tolerance, impaired fasting glucose, or an HbA1c between 5.7% and 6.4% should be referred for behavioral counseling focused on weight, diet, and exercise. To prevent these patients from developing T2DM, metformin therapy should be considered. This is especially true if the individual has a body mass index (BMI) over 35, is over age 60, or is a woman who has had gestational diabetes mellitus during a pregnancy.⁴

For patients with prediabetes, the goal is to keep them from advancing into diabetes or, in a best-case scenario, to reverse their prediabetes status. “The bang for the buck is in [dealing with] prediabetes,” said Meece.

Getting people to keep their condition under control and prevent it from progressing will pay off in the long run as they - and the healthcare system - avoid the costs of treating diabetes and its accompanying problems. “You can prevent type 2 diabetes. It is a preventable problem,” Meece said.

Meece compared prediabetes to a cliff; people walk off the edge and crash to the bottom into type 2 diabetes and all its complications. The healthcare system can build roads to the bottom of that cliff and have ambulances standing by to take the fallen to the hospital. “But no one says, ‘Why not build a fence at the top to keep people from falling off that cliff?’” he said.

Pharmacists can intervene

Tracey TaveiraPharmacists are ideally suited to help prediabetic patients avoid the advance into diabetes: “This is where the pharmacy can become such a huge factor,” Meece said. Pharmacists should guide patients with lifestyle management issues and help them increase their physical activity levels and improve their nutrition, as well as monitor their medication therapy.

“Since community pharmacists are highly accessible and free to consult, they are the ideal healthcare professionals to provide diabetes education,” said Tracey Taveira, PharmD, CDOE, professor at the University of Rhode Island College of Pharmacy in Kingston and adjunct professor at Brown University School of Medicine in Providence.

Screening programs can be a regular feature at a pharmacy, noted Marquess, whose pharmacies in Georgia offer monthly blood-glucose screenings for diabetes. His staff also visits local senior centers and community groups to conduct screenings. Almost every screening event his pharmacies present identifies someone with impaired blood glucose or diabetes, he said.

The patient as expert

Evan SissonOne of the first things a pharmacist can do when counseling a patient with prediabetes is to determine the patient’s needs and motivations for change, said Evan Sisson, PharmD, CDE, FAADE, associate professor in the Department of Pharmacotherapy and Outcomes Science at Virginia Commonwealth University School of Pharmacy in Richmond.

In Virginia, pharmacists can enter into a collaborative practice with physicians to co-manage patients, said Sissson, who co-manages patients with prediabetes and diabetes. The physician evaluates the patient and makes the diagnosis, and then refers the patient to a pharmacist or nurse practitioner who then manages and monitors the therapy.

Counseling patients with either prediabetes or diabetes means explaining the importance of three things, Marquess said. “When I meet with them I tell them there are three key factors - interventions - that they must pay attention to and work on through their lifetime.” Patients must be educated about keeping an equal focus on weight management, which includes portion control and carbohydrate consumption; physical activity; and adherence to taking their medications as instructed, he said.

“You can do all of these things if you have a personal relationship with a local pharmacist,” Marquess said. “I’ve heard people say they will do one or two of the three, but it doesn’t work that way.”

The person who is an expert on the patient is the patient, he said. “Most people have an idea of what is the hardest thing for them or what is a real barrier between them and ideal health.” It also pays to understand the patient’s own needs, said Marquess, citing the example of a construction worker or a letter carrier who walks a route. These individuals do not need a 10-minute talk about physical activity because getting enough exercise is not their main problem, he said.

Meece added that he sees many patients who have developed a fatalistic approach to their prediabetes. “It becomes a self-fulfilling prophecy,” he said.

 “Most adults are problem-based learners, meaning that they learn best when they are presented with an issue or barrier to care and receive education on the resolution, rather than sitting through a one- to two-hour lecture about everything they need to know on a particular topic,” Taveira said. Frequent, brief interventions performed by a highly knowledgeable healthcare professional are an ideal way to provide prediabetes or diabetes education to adults.

Diabetes prevention

Sisson works with patients with prediabetes and diabetes in a classroom space at a free clinic in Richmond, using the 16-week curriculum from the CDC’s Diabetes Prevention Program (DPP). The curriculum is based on a 2002 clinical study of the same name, which showed that a lifestyle modification program was more effective than treatment with metformin in keeping prediabetic people from developing diabetes.

“What is really nice about DPP is that we have good data to show that this works,” Sisson said.

The curriculum, which is free and available at the CDC website, covers topics for diabetes self-management, including diet, physical activity, and adherence to medication regimens.⁵

“Anyone who wants to can put this program in place. You don’t need to reinvent the wheel,” said Sisson. In addition, pharmacies can list their programs at the CDC site, which allows people looking for diabetes education classes to find them, he added.

The DPP curriculum works well with the free clinic’s population, whose level of health literacy is lower than that of the general population, reinforcing the concepts participants need to know and giving them tools they can use to improve their health, said Sisson.

Counseling in the pharmacy

Educational programs such as DPP are an excellent way to counsel and educate patients, but not every pharmacy has the space or staff needed to provide them.

“It is very difficult if you are a one-man or one-woman shop,” said Marquess. But counseling someone with prediabetes need not be a lengthy process. A pharmacist can have a two- or three-minute interaction with patients each month when they pick up their prescriptions. One month, they can have a quick conversation about portion control; the next month they might talk about nutrition, he suggested.

Meece agreed. “You can do an awful lot in five and 10 minutes,” he said. “It can be short and sweet.” Simply having medical scales in the pharmacy can help, because people can quickly check their weight.

 “I have spoken with community pharmacists who have said that on days when they are particularly busy, they will staple their business cards to glucometer prescriptions and advise patients to come back at the end of their shifts, so that they can provide more extensive individualized education then,” Taveira said.

Marquess, too, meets with patients most days, he said.

A pharmacist does not have to be a certified diabetes educator to get the message across to people with prediabetes, Meece pointed out. “I know a lot of pharmacists who are good diabetes educators who are not CDEs.”

Reimbursement

One issue connected with counseling patients with prediabetes is the lack of reimbursement. Time spent advising prediabetic patients about lifestyle issues will usually not be reimbursed in the way that it might be reimbursed for diabetic patients, said Meece. “Reimbursement is always an issue, for the doctor or the pharmacy.”

The lack of reimbursement may mean that the counseling that could help prevent prediabetic people from progressing to diabetes may not happen in the average pharmacy, Meece said, where “what gets paid for is what gets done.” 

“We are probably going to have to show that this is effective before we get reimbursed,” he added.

On the other hand, counseling for patients with diabetes is reimbursable if the pharmacy has a program that is accredited by the American Academy of Diabetes Educators, Meece said; “our pharmacy is a hybrid pharmacy-wellness center,” with classes for people with diabetes. A smattering of people with prediabetes attends the classes, he added, but there is no reimbursement for such individuals. 

For pharmacists seeking to counsel patients with prediabetes and diabetes, he suggested pursuit of a collaborative practice model, similar to the type used in Virginia, or contracting with businesses and companies to provide diabetes screening and education.

Valerie DeBenedetteis a medical news writer in Putnam County, N.Y.

References

1.     Centers for Disease Control and Prevention. Diabetes Report Card 2014. Atlanta, Ga. Diabetes 2014 Report card. U.S. Department of Health and Human Services; 2015. bit.ly/diab2014. Accessed Sept. 3. 2015.

2.     American Diabetes Association. Diagnosing diabetes and learning about prediabetes. www.diabetes.org/diabetes-basics/diagnosis. Accessed Sept. 20, 2015.

3.     American Diabetes Association. Economic burden of prediabetes up 74% over five years. bit.ly/econburden. Accessed Sept. 22, 2015.

4.     American Diabetes Association. Standards of medical care in diabetes: 2015. Diab Care. 2015;38 (suppl 1):S1-S93.

5.     Centers for Disease Control and Prevention. The CDC Diabetes Prevention Program (CDC DPP) Curriculum. bit.ly/curriculumNDPP. Accessed Sept. 24, 2015.