Brian K. Irons

A Retrospective Cohort Analysis of the Clinical Effectiveness of a Physician‐Pharmacist Collaborative Drug Therapy Management Diabetes Clinic

The glycemic control of patients with diabetes in a physician‐supervised, pharmacist‐managed primary care clinic was compared with that of patients receiving standard care in the same health care system. We retrospectively analyzed the glycemic control of 87 men with type 1 or type 2 diabetes whose diabetes‐related drug therapy was managed by clinical pharmacists compared with a control group of 85 similar patients whose care was not augmented by clinical pharmacists. Primary outcomes were differences in fasting blood glucose (FBG) and glycosylated hemoglobin (A1C) levels between groups. Secondary outcomes were relative risk (RR) for achieving an A1C of 7% or below, frequency of diabetes‐related scheduled and unscheduled clinic visits, and frequency of hypoglycemic events. The study group had 864 clinic visits and the control group had 712 between October 1997 and June 2000. No statistical differences were noted in FBG or A1C between groups. The RR of achieving an A1C of 7% or below was significantly higher in the study cohort (RR 5.19, 95% confidence interval [CI] 2.62‐10.26). The frequency of hypoglycemic events did not differ between groups. The mean ± SD frequency of unscheduled diabetes‐related clinic visits/patient/year was higher in the control group (1.33 ± 3.74) than in the study group (0.11 ± 0.46, p=0.003). Pharmacist‐managed diabetes care was effective in improving glycemic control and was not associated with an increased risk for hypoglycemic events or unscheduled diabetes‐related clinic visits.

Pharmacy- and Community-Based Screenings for Diabetes and Cardiovascular Conditions in High-Risk Individuals

OBJECTIVE To assess a model to screen minority, elderly, and at-risk individuals for diabetes, hypertension, and dyslipidemia in pharmacy and non-health care settings. DESIGN Multicenter, prospective, observational trial. SETTING 26 pharmacies and 4 non-health care settings. PARTICIPANTS 888 individuals with one or more of the following risk factors: first-degree relative with diabetes, age 55 years or older, obesity, previous diagnosis of hypertension, or a previous diagnosis of dyslipidemia. INTERVENTION Measurement of plasma glucose, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and blood pressure; risk assessment using a risk factor tool; referral of participants with abnormalities to physicians. MAIN OUTCOME MEASURES Adherence with follow-up, physician recommendations, and new diagnoses of diabetes, hypertension, and dyslipidemia. RESULTS Pharmacists screened 888 participants in pharmacies and non-health care settings; 794 scored at least 10 on the risk factor tool and received further screenings. Of these, 81% were referred for follow-up for at least one abnormality: 15% glucose, 68% blood pressure, 66% total cholesterol, and 26% HDL-C. For those referred, the mean (+/- SD) fasting plasma glucose concentration was 179 +/- 87 mg/dL, and the random glucose concentration was 234 +/- 90 mg/dL. Of participants completing follow-up, 16% received one or more new diagnoses as follows: diabetes, 8; hypertension, 9; and dyslipidemia, 29. Therapy changed for 42% of participants. Participants who were elderly, of African American and Hispanic race/ethnicity, or those with elevated cholesterol values were at significantly greater risk for elevated glucose levels. Screenings in community pharmacy settings had improved follow-up rates with physicians compared with screenings conducted in non-health care settings. CONCLUSION Pharmacists identified individuals with elevated glucose, cholesterol, and blood pressure values through community-based screenings. Pharmacists also identified individuals who could benefit from further control of previously diagnosed hypertension and hyperlipidemia.

Implications of Rosiglitazone and Pioglitazone on Cardiovascular Risk in Patients with Type 2 Diabetes Mellitus

Clinical data suggest that thiazolidinediones—specifically, rosiglitazone and pioglitazone—may improve cardiovascular risk factors through multiple mechanisms. Low insulin sensitivity has been described as an independent risk factor for coronary artery disease and cerebrovascular disease. Patients with insulin resistance often have several known risk factors, such as obesity, dyslipidemia, and hypertension. Other emerging risk factors may be prevalent in patients with insulin resistance, such as hyperinsulinemia, elevated C‐reactive protein, elevated plasminogen activator inhibitor levels, and small, dense, low‐density lipoproteins. The only available drug class that primarily targets insulin resistance is the thiazolidinediones. These drugs have shown efficacy in affecting surrogate markers of cardiovascular risk in patients with diabetes mellitus. Alterations in these risk factors are likely due to their effects on improving insulin sensitivity and/or glycemic control. Trials to assess whether thiazolidinediones actually reduce cardiovascular outcomes are continuing.

Delaying the Onset of Type 2 Diabetes Mellitus in Patients with Prediabetes

The frequency of type 2 diabetes mellitus is increasing at an alarming rate. Prediabetes, also referred to as impaired glucose tolerance (IGT) and/or impaired fasting glucose, is a major risk factor for development of type 2 diabetes mellitus. In addition, IGT has been associated with an increased risk of cardiovascular disease and mortality. Several studies have measured the effects of various interventions in patients with IGT on the development of type 2 diabetes mellitus. Intensive lifestyle modifications through alterations in diet and improvement in exercise have delayed the development of type 2 diabetes mellitus by 58% in patients with IGT. Therapy with metformin, troglitazone, or acarbose also has reduced the progression of IGT to diabetes mellitus by 31%, 49% and 25%, respectively. The mechanisms by which lifestyle interventions and drugs reduce the progression may be through alterations in insulin sensitivity. The American Diabetes Association recommends screening for prediabetes in patients who are 45 years or older and those with a body mass index of 25 kg/m2 or greater who have additional diabetes mellitus risk factors. Pharmacists can promote awareness, counsel patients on intervention strategies to delay the onset of diabetes mellitus, and screen high‐risk patients.

Quality of care of a pharmacist-managed diabetes service compared to usual care in an indigent clinic.

BACKGROUND This study evaluates the quality of care of a pharmacist-managed diabetes clinic focused on an indigent population and compares that quality of care to usual care in the same health care setting. METHODS Two groups of subjects were evaluated by retrospective review of medical records. The experimental group (n = 47) consisted of patients whose care was facilitated by a clinical pharmacist (medication initiation and modification, laboratory and physical assessment) in addition to routine physician care. A control group (n = 45) consisted of patients not referred to the pharmacy service whose care was provided solely by a physician. Changes in glycemic, blood pressure, and lipid control were assessed as were use of specific medications. RESULTS After an average of 1.8 years of follow-up, a larger reduction in hemoglobin A1C was observed in the experimental group (2.0%) compared to the control group (1.2%), but the difference was not statistically different. Both groups experienced significant improvements in blood pressure control with a higher absolute increase from baseline in the experimental group compared to the control group (34% vs. 22% respectively, P < 0.001). Low-density lipoprotein-cholesterol levels in the control group fell by 2 mg/dL, while a 29 mg/dL reduction was observed in the experimental group (P < 0.001). While aspirin, angiotensin-converting enzyme inhibitor, and angiotensin receptor blocker therapies were not different between the two groups, statin therapy was significantly improved in the experimental group (from 23% to 68%) compared to the control group (from 33% to 44%) (P = 0.038). CONCLUSIONS Many key diabetes quality of care outcomes in an indigent population were significantly improved in patients whose diabetes management was facilitated by a clinical pharmacist.

Third‐Line Agent Selection for Patients with Type 2 Diabetes Mellitus Uncontrolled with Sulfonylureas and Metformin

Patients with type 2 diabetes mellitus often begin treatment by taking oral agents, usually metformin or a sulfonylurea, and then progress to the combination of these two agents. Most patients often require three or more agents or a change to an insulin regimen. However, no guidelines are available to aid the clinician in the decision‐making process for selecting the third agent. Many options are available for additional therapy, including thiazolidinediones, intermediate‐ and long‐acting insulins, exenatide, and dipeptidyl peptidase‐4 inhibitors. Although the American Diabetes Association recommends metformin as first‐line therapy, it does not give exact specifications for second‐ and third‐line agents but only summarizes clinical data and options about each therapeutic drug class. Guidelines from the American College of Endocrinology and American Association of Clinical Endocrinologists recommend several options depending on the patients hemoglobin A1c level. Therefore, a standard of care cannot be provided; rather, clinicians must evaluate each patient to ascertain that patients optimum therapy. In doing so, clinicians need to be familiar with the efficacy, safety, and cost of each agent.

Opinions of West Texas pharmacists about emergency contraception

Background The pharmacist’s role in dispensing emergency contraception (EC) has become controversial due to the intersection of personal and professional ethics. Therefore, to examine the issue of EC availability, we surveyed a sample of West Texas pharmacists. West Texas is a religiously and politically conservative region where no methods of EC have been made available. Objective to survey a sample of pharmacists in West Texas about their experience, beliefs, and knowledge of EC both before and after a presentation of the current literature about EC. Methods We asked a convenience sample of 75 pharmacists about their experience, beliefs, and knowledge of EC both before and after a presentation of the current literature about EC. Results Sixty-four (85%) pharmacists agreed to complete the study questionnaire. None carries EC in his/her pharmacy, and scientific understanding of EC was generally poor. Fourteen percent stated EC conflicts with their religious views, 17% considered it a method of abortion, 11% would not be willing to fill an EC prescription written by a doctor. 58% would be willing to offer EC over the counter. The presentation encouraged more to offer it over the counter, but in general did not significantly change their beliefs. Conclusion Our sample of West Texas pharmacists demonstrated very little experience with, a general lack of knowledge about, and some personal and religious objections to EC.

Lipid Management with Statins in Type 2 Diabetes Mellitus

OBJECTIVE: To provide an update on lipid management and recent modifications in cholesterol guidelines for use of hydroxymethylglutaryl coenzyme A reductase inhibitors (statins), specifically in patients with diabetes. DATA SOURCES: Studies and guidelines were identified through a MEDLINE search (1996–April 2005). STUDY SELECTION AND DATA EXTRACTION: Studies were selected for review if the primary treatment intervention was a statin, at least 4% of the study population held a diagnosis of diabetes, and diabetes subgroup analysis was available. DATA SYNTHESIS: The Heart Protection Study demonstrated an approximately 25% relative risk reduction of a first coronary event in patients with diabetes, a reduction similar to those without diabetes. In subjects with diabetes, a significant reduction in coronary events was noted regardless of the baseline cholesterol level. The Collaborative Atorvastatin Diabetes Study demonstrated a 37% relative risk reduction in the primary prevention of cardiovascular morbidity in patients with diabetes. CONCLUSIONS: Based on the current literature, a low-density lipoprotein cholesterol (LDL-C) level <100 mg/dL remains an appropriate goal for patients with diabetes in the absence of established cardiovascular disease. For higher-risk patients, such as those with diabetes and a history of cardiovascular disease, a more stringent LDL-C goal of <70 mg/dL is an option according to current clinical trial evidence. At least a 30–40% reduction in the LDL-C level is advisable when initiating statin therapy.

An Update in Incretin-Based Therapy: A Focus on Dipeptidyl Peptidase - 4 Inhibitors

Dipeptidyl peptidase -4 inhibitors represent a novel way to augment the incretin system and one of the newest class of medications in the treatment of type 2 diabetes mellitus. Their mechanism of action is to decrease the inactivation of glucagon-like peptide 1 and glucose-dependent insulinotropic polypeptide, both of which are involved in maintaining euglycemia subsequent to carbohydrate intake. Currently investigated agents include sitagliptin, vildagliptin, saxagliptin, linagliptin, and alogliptin. Each agent has been shown to provide significant improvements in glycemic control compared to placebo. They are effective when added to other oral diabetes agents and in the cases of sitagliptin, vildagliptin, and alogliptin in addition to insulin. These agents may not provide as significant improvement in glucose concentrations as some other medications including metformin, thiazolidinediones, or glucagon-like peptide 1 agonists. The lack of head to head clinical data comparing the various dipeptidyl peptidase 4 inhibitors does not allow for specific recommendations if one agent is more effective or safer than another within the class. Their side effect profile suggests they are very well tolerated and have few drug interactions. For patients with mildly elevated glucose concentrations, they are therapeutic options in both drug-naive patients as well as those not optimally controlled on other diabetes medications.

Factors Associated with Increased Hospital Utilization in Patients with Heart Failure and Preserved Ejection Fraction

Study Objective. To determine whether controlling systolic blood pressure (SBP), pulse pressure, and heart rate in the outpatient setting is associated with decreased hospital utilization in patients with heart failure and preserved ejection fraction (PEF).