CHALLENGES FOR PATIENTS USING INTENSIVE INSULIN THERAPY
Diabetes is a challenging disease for patients and caregivers to manage. For some patients, the use of insulin is required to achieve glycemic control but it can have significant adverse consequences if not used appropriately. Incorrect administration of insulin (too little, too much, or at the wrong times) can result in both transient and serious hypo- and hyperglycemia, severe hypoglycemia, and diabetic ketoacidosis.
Patients with Type 1 (T1D) and Type 2 diabetes (T2D) who are using intensive insulin, defined as three or more injections of insulin per day or the use of an insulin pump, may have frequent unrecognized episodes of hypoglycemia during the day and at night. These frequent episodes can result in a patient’s awareness of hypoglycemia becoming impaired, where they have trouble “feeling their lows” and leaving them more at risk for severe hypoglycemia and its potential consequences of seizures, coma, or even death.
The American Diabetes Association recommends that patients using intensive insulin monitor their blood glucose levels at least 6 to 10 times per day in order to make diabetes treatment decisions regarding diet, lifestyle, and the safe and effective use of their treatment. Unfortunately, due to the pain, burden and inconvenience of fingerstick testing, many patients test far fewer times than recommended to successfully manage their disease.
Due to the stress and consequences of hypoglycemia, many patients on intensive insulin and even their caregivers may develop a fear of hypoglycemia and will test with fingersticks throughout the night to prevent a seizure or even death due to a hypoglycemic episode. Unfortunately, most patients and caregivers then decide to use less insulin than prescribed, leaving the patient hyperglycemic with essentially uncontrolled diabetes.
For many patients and caregivers, monitoring with fingersticks is difficult and does not provide enough information to manage their diabetes with the stress affecting their sleep, quality of life, and productivity at school and work.
OPPORTUNITY FOR PHARMACISTS
Pharmacists are considered one of the most trusted and accessible health care professionals. For this reason, they are afforded the opportunity to identify patients and caregivers who may be struggling with diabetes management and offer solutions such as real-time continuous glucose monitoring (CGM). CGM is increasingly recognized as the standard of care for people with T1D and insulin-requiring T2D and one of the most important advances in managing T1D since the discovery of insulin.
Ronald Simbulan, RPh, Director, Mail Order and Specialty Pharmacies at RWJBarnabas Health in West Orange, New Jersey conducted an outreach program to employees and dependents who were using mealtime insulin. Patients were informed that CGM could help them manage their diabetes and if they agreed, the pharmacy would contact their provider to obtain a prescription for CGM.
“We needed to help our employees and dependents with diabetes manage a difficult disease and, based on the evidence, we felt that recommending real-time CGM to those who could benefit was important,” Simbulan noted.
The education and outreach by the pharmacy was appreciated, with many patients agreeing to have the pharmacist discuss CGM with their provider and to request a prescription. “Don’t assume that the patient’s doctor discussed CGM – we found that most patients who could benefit from CGM weren’t even aware that it was available as an option for them,” Simbulan advised.
DEXCOM REAL-TIME CONTINUOUS GLUCOSE MONITORING
The Dexcom G6 is the only real-time CGM that is FDA approved for patients ages 2 and older. The user or caregiver can make diabetes treatment decisions without confirmatory fingersticks or calibrations.*
The Dexcom G6 is approved for patient self-start and uses a simple one-touch auto-applicator to insert a small water-resistant sensor just beneath the skin. The sensor continuously measures glucose levels and sends data wirelessly to a display device through a transmitter. The display device is either a small touch screen receiver or a compatible smart device, which displays realtime glucose data with rate and direction 24 hours a day. The system alerts patients when it is time to change sensors and transmitters; the sensor is replaced every 10 days and transmitters are replaced every 90 days.
The glucose readings with rate and direction help Dexcom CGM users proactively manage glucose highs and lows, plus give added insight into the impact that meals, treatment, exercise, and illness may have on their glucose levels. Dexcom CGM users are also notified with customizable alerts and alarms if their glucose is heading high or low, allowing them to take action to prevent and/or treat the high or low glucose levels.
The CGM data can also be shared with up to 10 followers who will receive the user’s glucose data in real time and can then check in or assist if needed. Users can also allow their providers access to the last 90 days of their glucose readings via CLARITY software reports. The diabetes management application, CLARITY, lets providers and patients identify glucose trends and patterns to assist in making changes to the diabetes management plan.
There have been tremendous advances in CGM technology; in fact, CGM is an emerging standard of care in diabetes management, particularly for patients with T1D and T2D using three or more insulin injections per day or receiving insulin through a pump.
Pharmacists are uniquely positioned to identify patients with diabetes who are struggling with the challenges of using their insulin safely and effectively and could benefit from continuous glucose monitoring. The value of real-time CGM glucose data cannot be understated, as studies have shown that CGM use can result in lower A1c values and reductions in hypoglycemia and hyperglycemia for patients of all ages, education levels, and mathematical ability.
The Dexcom system is available through all pharmacy wholesalers, and access and coverage are increasing, with many insurers covering the technology through the pharmacy benefit. Additionally, Medicare currently covers CGM for patients with T1D and T2D who are using intensive insulin treatment.
To learn more, Dexcom’s website (https://www.dexcom.com) offers a wealth of educational content, videos, and promotional print materials to share with patients, which are available upon request. Also, CGM continuing education for pharmacists is available on https://cgmeducation.net/ and https://www.powerpak.com/course/preamble/118584.
Please contact Roy Thomas, PharmD at firstname.lastname@example.org for more information on how CGM can be incorporated into your pharmacy practice for patients with diabetes.
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