Treating the Diabetic Epidemic Effectively: Pharmacists as Key Contributors to the Cause
James C. McAllister III, MS, FASHP*
In a recent New England Journal of Medicine article about the diabetes epidemic in New York City, the authors reported that the city now requires laboratories to report hemoglobin A1c to the city's Department of Health and Mental Hygiene.1 This report was a true wake-up call. Although numerous reports about the diabetes epidemic have been released recently, few people are aware that diabetes has become, in every sense, a profound and pervasive national health crisis.
This issue of University of Tennessee Advanced Studies in Pharmacy highlights the proceedings of a pharmacist roundtable discussion on the diabetes epidemic in America, held June 30, 2006, in Chicago, Illinois. The objective of the meeting was to explore current and emergent approaches for addressing this crisis for pharmacists in a variety of practice settings: community pharmacy, hospitals and their ambulatory clinics, and managed care. At the roundtable, it became clear that, as an academic administrator overseeing the activities of more than 100 pharmacists associated with the University of North Carolina Hospitals and Clinics, I was in a unique position to do something about this crisis. The distinguished faculty members contributing to this discourse were uniquely positioned to elucidate my role. It is my personal belief that every pharmacist in America has an opportunity to make a real and significant contribution to this effort, and that the information in this monograph will provide you with the tools needed to begin that process.
As Susan Cornell, PharmD, CDE, CDM, from Midwestern University, Chicago College of Pharmacy, reports in her article on the scope of the problem, the number of persons diagnosed with diabetes mellitus has increased 4- to 6-fold over the last 50 years.2 Of particular concern is the dramatic increase in type 2 diabetes mellitus (T2DM) among younger populations, with a 50% increase in children aged 13 to 18 years.3,4
As Tommy Johnson, PharmD, CDE, from the University of Georgia College of Pharmacy, reports in his article, "Comorbidities and Complications of Poor Glycemic Control," the human costs of T2DM are immeasurable. Complications of the illness include vision loss, limb amputations, cardiovascular disease, microvascular and macrovascular diabetic complications, and many other comorbidities—all of which will begin to affect some children before they graduate from high school.
For those who wish to learn more about new areas of scientific inquiry in diabetes management, the article by David W. Bartels, PharmD, BCPS, CDE, of the University of Illinois at Chicago, will provide intriguing insights about evolving therapeutic approaches. His article focuses on peroxisome proliferator-activated receptors, a new class of medications that are effective in managing hyperglycemia and hyperlipidemia.
The Diabetes Prevention Program has demonstrated that lifestyle interventions, including dietary changes, increased physical activity, and weight loss, are the most effective means of preventing T2DM.5 As the medical community perseveres to work with patients to achieve these goals, pharmacologic interventions continue to improve. Pharmacological management represents a potential breakthrough in treating diabetes, in addition to its complications and comorbidities.
To effectively improve diabetes management, pharmacists must adopt an uncompromising "treat to target" approach to care. This approach involves earlier pharmacologic interventions and persistent titration of medications to achieve and maintain glycemic targets safely. A combination oral or oral/insulin therapy in conjunction with medical nutrition therapy and other lifestyle interventions as initial treatment may be required. The goal is to achieve target glycemic control as early as possible. By counseling patients about why this goal is important to their health and how they can best achieve it, pharmacists can help make their goal a reality.
Given new developments in the prevention and management of diabetes, pharmacists must work closely with physicians, nurses, diabetes educators, and patients to integrate these emerging breakthroughs into clinical practice to improve outcomes. Pharmacists can play an important role by screening patients at high risk for diabetes, assessing patient health status and adherence to standards of care, encouraging patients to care for themselves, referring patients to other healthcare professionals as appropriate, and monitoring outcomes. Providing diabetes management services requires communication skills, in addition to a commitment of time, effort, and resources.6 Improving diabetes management services can begin with the individual pharmacist creating a ripple of change in his or her environment.
1. Steinbrook R. Facing the diabetes epidemic--mandatory reporting of glycosylated hemoglobin values in New York City. N Engl J Med. 2006;354:545-548.
2. Engelgau MM, Geiss LS, Saaddine JB, et al. The evolving diabetes burden in the United States. Ann Intern Med. 2004;140:945-950.
3. Mokdad AH, Ford ES, Bowman BA, et al. Diabetes trends in the U.S.: 1990-1998. Diabetes Care. 2000;23:1278-1283.
4. Wyne KL. The need for reappraisal of type 2 diabetes mellitus management. Postgrad Med. 2003;Spec No:5-14.
5. National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes prevention program: questions & answers. Available at: http://www.niddk.nih.gov/patient/ dpp/dpp-q&a.htm. Accessed September 12, 2006.
6. Campbell RK. Role of the pharmacist in diabetes management. Am J Health Syst Pharm. 2002;59(suppl 9):S18-S21.
*Director of Pharmacy, University of North Carolina Hospitals, Chapel Hill, North Carolina.
Address correspondence to: James C. McAllister III, MS, FASHP, Director of Pharmacy, University of North Carolina Hospitals, University of North Carolina Hospital Pharmacy Administration, 101 Manning Drive, Chapel Hill, NC 27514. E-mail: JMcAllis@unch.unc.edu.
The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.