Role of the Pharmacist in Diabetes Care

By Robert S. Roscoe, B.Sc., CDE, CPT

The incidence of diabetes is increasing and, as a result, has put a strain on our healthcare resources especially when it comes to providing clientele with information and management of their disease state. The Diabetes Education Center provides the most comprehensive program, from all inclusive group classes to one-on-one sessions, but is struggling to keep up with the demand.

As the gap widens pharmacists have recognized the need to become part of the diabetes education team and help fill the void by starting the education process. Pharmacists have five years of university training including academic and practical rotations. During this time we establish a good understanding of diabetes and co-morbidities including cardiovascular and kidney disease. The background of these disease states, coupled with our knowledge of prescription medicine, places pharmacists in an ideal position to help initiate the learning and educational process on the patient’s journey with their diabetes. As important, with our ever constant availability for Over-the-Counter (OTC’s) issues, we are in an advantageous position to help our clients with diabetes make crucial decisions on foot care, skin care, eyes care, oral hygiene, cough and cold products, etc. Also, by being readily available we have the potential to identify someone who may have signs and symptoms of diabetes and help direct them for appropriate screening.

Pharmacists are also becoming more involved in the issues of compliance and adherence to a particular medication regimen. Our software developers are releasing different forms of compliance programs that will help monitor refill intervals and notify pharmacists when a patient may not be taking their medication as prescribed. With this information we may then be able to contact them to help identify non compliance issues. Is it side effects? Do they not understand how to properly take the medication? Is it related to cost? Are they missing a particular dose in a multiple dose day, i.e., missing their lunchtime dose in a four times a day regimen? By increasing compliance we can help reduce disease progression which improves the patient’s outcome, may reduce extra costs due to additional medications, could provide more efficient use of tax and insurance dollars by reducing wastage and again maximize the reduction of disease progression by helping assure that patients are taking their medications as prescribed.

At the very least we pharmacists should be providing the basic needs of our patients with diabetes. By providing blood glucose meter training and showing clients how they can at least monitor their condition. Having the patient understand their medications and how best to take them and what to expect while taking them, including expectations and side effects. As well as providing basic information so the patient gets some understanding of their diabetes while they are waiting to enroll in diabetes education classes. The pharmacist’s function is such that a patient may see us more often than they would see their physicians, specialists and diabetes educators and can usually “drop in” to see us without an appointment. So there is an opportunity for us to expand our role by stepping into the education process.

Pharmacy is an on demand service as we must first process and fill prescriptions and that is the traditional role most people still ascribe to us. But the role of the pharmacist is rapidly expanding with restricted prescribing occurring in certain provinces. As a profession we are now increasing our duties by being certified in other areas such as Asthma, Co-Agulation, and of course Diabetes (Certified Diabetes Educator-CDE). At last count there were approximately 7-8 CDE/Pharmacists in the province of N.B., and many more Canada wide. We are the fastest growing segment of Certified Diabetes Educators. This will hopefully allow us to offer our patients more detailed assistance in their disease management and monitoring.

As a quick reference, see below for a list of what can be provided (depending on location).

BASIC (all pharmacies have this potential) :

• Provide Blood Glucose Meters and SHOULD provide detailed instructions on how to use them.
• Insulin supplies. Testing supplies etc.
• Have available basic information (CDA based, Store based, etc.) on diabetes.
• Know where the patient can go for further info (Diabetes Education Center, websites, support groups etc.)
• SHOULD provide information on their client’s diabetes medications and how to use them.

ADVANCED (Pharmacies with an interest in diabetes, especially those with CDE/Pharmacists). As above but may now include:

• Insulin pen training and supplies (separate from Insulin starts) ** PLEASE NOTE** process of providing insulin pens is changing and should be more readily available at most locations.
• Insulin Pump supplies- again may not be easily, readily available.
• More detailed information on client’s disease states especially the ability to answer questions as the patient drops in to see us. The patient learns as they need to. Less formal addressing of concerns as they occur (on demand).
• Relating the numbers the pharmacist sees from their client’s tests to certain circumstances (i.e. meals, sick days, special events, medication etc).
• Set up clinic days where we provide screening for patients and give information on diabetes.

If the pharmacist/CDE has a real interest in diabetes, it includes all the above and adds more services as well, this could include:

• Insulin starts based on family doctor recommendations and per protocol that includes survival issues and the use of insulin (i.e. sick day, hypos, proper injection technique, insulin action, mealtimes, blood glucose test pattern etc).
• Includes detailed insulin pen training and supplying pens as required.
• With approval of physician make appropriate adjustments.
• As a Certified Insulin Pump Trainer provide liaison on pump issues that users may face both from supply issues to therapeutic issues.
• As a Certified Pump Trainer may provide sessions to upgrade versions of pumps (one-on-one). I have started pumps from scratch but in our region starts are generally done through our Education Centers.
• As a “Certified Sensor Trainer” provide one-on-one sessions with patients that are going on the Continuous Blood Glucose Monitor (CGM).
• Download meters and help patient understand readings, make therapeutic recommendations based on how their control has been.
• Provide med review and recommend change of therapies or dose adjustments. (e.g. re-introduce Glumetza in patients unable to tolerate plain Metformin).
• Provide Community based lectures on diabetes and its treatment. These include company wellness days, CDA Signature series lectures, church and support style groups.
• Provide CHE, CME, and educational sessions to other professionals on diabetes, its management, and devices used to manage and monitor their condition.
• Act as a consultant to companies involved with diabetes care to help ensure that programs and devices will be practical and useful.
• Act as an advocate for diabetes care in New Brunswick by increasing awareness of the disease. Diabetes Care Map for NB, CDA hosted members dinner (politician based supper, etc.).
• Act as an advocate for pharmacists’ involvement in diabetes management by being part of Task Forces in Diabetes. I now sit as a retail pharmacist on The Diabetes Task Force of New Brunswick which reports to the Minister of Health.

One can see there are many levels that can be provided by your local pharmacy. It is best to find a location that has a pharmacist who has an interest in diabetes as you may find that there will be more services available for the patient at these locations. Hopefully this will help show that we just don’t count pills (an old view). The new term “get to know your pharmacist” may actually be a pleasant surprise as we have the ability to do so much more. We also provide one stop shopping for all diabetes care products.

We, as a group, are eager, enthusiastic health professionals who want to become part of the Diabetes Care Team. As pharmacists we have long identified the need to act collaboratively with other professions to benefit our common clients with diabetes. Diabetes is such a complex disease state that a consistent message delivered by a multidisciplinary healthcare team would only benefit our clients as well as ourselves as we work together to reinforce the same approach.

We need to be there for our clients as they journey down their path with diabetes. As pharmacists, we are also on our own journey from “the keepers of medication” to more of a disease state manager with additional responsibilities such as restrictive prescribing and the need to act collaboratively with our fellow health professionals in order to best serve our patients with Diabetes.

About the Author

Robert S. Roscoe is a Pharmacist, CDE and a CPT (Certified Insulin Pump Trainer). A Dalhousie University graduate, Rob completed his Hospital Pharmacy Residency at the Saint John Regional Hospital in Saint John, New Brunswick. He worked at various hospitals in the Maritimes before he found his niche in retail pharmacy. Since obtaining his CDE in 2004, Rob has been a constant advocate for pharmacist’s involvement in patient diabetes care. He is a member of the Diabetes Task Force which reports to the Minister of Health for New Brunswick on managing/ treating people with diabetes in the province.

Rob was recently acknowledged by the CDA when he was awarded the “Regional Outstanding Health Professional 2007”. In addition, he was awarded Wyeth’s “Apothecary Award 2008” which recognizes a pharmacist who has obtained advanced training AND is putting that training to use in his daily practice. In 2009, the Canadian Pharmacists Association named him as one of Canada’s “Diabetes Champions for Canadian Pharmacists”.