Achieving Glycemic Control in Type II Diabetes: Where Are We in 2008?
L. Brian Cross, PharmD, CDE*
Diabetes mellitus (DM) and its hallmark symptoms of polyurea and glycosuria have been described by ancient Egyptians, Romans, Greeks, and East Indians.1 With the discovery of the Islets of Langerhans cells by Paul Langerhans in Germany during 1869 and the observation of frequent urination of a depancreatized dog by Oskar Minkowski in France during 1901, DM became a pancreatic disorder.1 In 1922, a 12-year-old Canadian boy named Leonard Thomson became the first patient with DM to be treated with a bovine pancreatic extract, later called insulin, developed through the collaboration of Frederick Banting (orthopedist), J.J.R. Macleod (physiologist), Charles Best (medical student), and James Collip (biochemist).1 Emaciated, debilitated, and not expected to live beyond a few years from diagnosis, Thomson was restored to good health within months of receiving recurrent insulin injections.1
During the 1930s, observations of adult-onset DM by the British physician Harry Himsworth led to the notion that DM may be caused not only by a lack of insulin, but also by a lack of sensitivity to insulin.2 His work, along with further investigation during the 1950s by the American researchers Rosalyn Yalow and Solomon Berson, led to the concept of insulin resistance associated with type 2 DM (DM2).2 Most notably, the work of Yalow and Berson demonstrated that a prediabetes syndrome existed, which revealed DM2 as a slowly progressive debilitating disease.
In just the last 3 decades, animal experimental and human observational studies have advanced the understanding of DM complications as related to hyperglycemia.3 Until the results of the United Kingdom Prospective Diabetes Study (UKPDS) in 1998, only 3 randomized controlled trials examined the correlation of glycemic control and complications in patients with DM2.3 The UKPDS, the largest and longest study of patients with DM2, confirmed the relationship of improved glycemic control with decreased microvascular and cardiovascular complications in patients with DM2. The results of the UKPDS have supported the American Diabetes Association's position that aggressive metabolic control of DM through the intervention of healthcare professionals can decrease morbidity and mortality associated with diabetic complications.3
Today, DM has become a worldwide epidemic and is one of the most costly and burdensome chronic diseases of modern times.4 Complications from DM can affect the renal, nervous, ocular, and cardiovascular systems, resulting in significant morbidity and mortality.4 Although advances in pharmaceutical care have improved the treatment of DM and its complications, recent studies are also focused on the prevention of DM2 and its complications.4 Historically, 2 underlying principles that have contributed to advancement in diabetes management are the collaboration of healthcare professionals and outstanding research design in clinical trials.
In recent decades, the evolution of pharmaceutical care services (PCSs) has encompassed the clinical, educational, and distributive functions of pharmacists in collaboration with other healthcare professionals.5 In addition to dispensing, core activities of PCSs include assisting with drug therapy decisions, providing education, and monitoring for adherence, adverse events, and disease outcomes.5 The goals of PCSs include improving clinical outcomes, maintaining disease control, balancing financial impact, increasing patient satisfaction, and ultimately enhancing patient quality of life.5 Cognitive services and patient-specific treatment plans are essential to the patient-pharmacist relationship of PCS. Patient self-management, which requires education and support from healthcare professionals, is also essential to effective treatment plans because self-management may significantly improve chronic disease progression.
Community pharmacists are among the most accessible healthcare professionals, and their active participation through PCSs could improve clinical outcomes of patients with DM2.5 As part of a multidisciplinary healthcare team, pharmacists are vital to comprehensive management of patients with DM2. Interventions and patient education by pharmacists could dramatically alter the progression of DM2 and its complications. Training and up-to-date knowledge in diabetes management will allow pharmacists to achieve professional competence and confidence in successful care of patients with DM2. Familiarity with pertinent clinical trial results and evidence-based treatment guidelines is vital to effective PCSs.
This issue of University of Tennessee Advanced Studies in Pharmacy begins with an overview of DM2 provided by Vivian A. Fonseca, MD, from Tulane University School of Medicine in New Orleans, Louisiana. Dr Fonseca reviews the growing prevalence of DM2, current treatment strategies for disease management, pertinent clinical trial results to guide therapeutic decisions, and the healthcare team approach to patient care. Additionally, Dr Fonseca illustrates the community pharmacist approach through the second case study, which describes a patient with DM2 in need of further education and counseling. The second article is provided by Condit F. Steil, PharmD, CDE, from Samford University, McWhorter School of Pharmacy in Birmingham, Alabama. Dr Steil focuses on the benefits of PCS through an effective relationship between pharmacists and patients with DM2. The first case study, as presented by myself and Charles D. Ponte, PharmD, BC-ADM, BCPS, CDE, FAPhA, FASHP, FCCP, demonstrates the importance of comprehensive PCS and healthcare professional collaboration for optimal care of patients with DM2.
As is true of many healthcare professionals, the desire to help patients is central to the motivation of pharmacists. Community pharmacists are well positioned to improve adherence, satisfaction, and outcomes in patients with DM2. Through collaborative care and an understanding of advancements in DM2 management, community pharmacists can optimize their patient relationships and achieve the rewards of their profession, contributing significantly to the quality of life for the patients they help to manage.
1. Raju TN. A mysterious something: the discovery of insulin and the 1923 Nobel Prize for Frederick G. Banting (1891-1941) and John J.R. Macleod (1876-1935). Acta Paediatr. 2006;95:1155-1156.
2. Patlak M. New weapons to combat an ancient disease: treating diabetes. FASEB J. 2002;16:1853.
3. American Diabetes Association. Implications of the United Kingdom Prospective Diabetes Study. Diabetes Care. 2003;26(suppl 1):S28-S32.
4. American Diabetes Association; National Institute of Diabetes, Digestive and Kidney Diseases. Prevention or delay of type 2 diabetes. Diabetes Care. 2003;26(suppl 1):S62-S69.
5. Gal P. Pharmacy practice in the era of managed care: considerations for change in practice and education. Consult Pharm. 1998;13. Available at: http://www.ascp.com/publications/tcp/1998/jan/feature1.shtml. Accessed September 25, 2008
*Associate Professor, University of Tennessee Health Science Center, Colleges of Pharmacy and Medicine, Memphis, Tennessee; and Pharmacotherapy Specialist, Holston Medical Group, Department of Disease Management, Kingsport, Tennessee.
Address correspondence to: L. Brian Cross, PharmD, CDE, Pharmacotherapy Specialist, Holston Medical Group, Department of Disease Management, Indian Path Medical Office Building, 2204 Pavilion Drive, Suite 110, Kingsport, TN 37660. E-mail: firstname.lastname@example.org.
The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his article and all its contents.