PHARMACY STORY

​

Initial Presentation:

A 61-year-old male patient with type 2 diabetes [Francis] came to Olden’s Pharmacy to pick up his medication refills. Francis had just come from a diabetes follow up with his primary care provider (PCP) and asked to speak to the pharmacist about some concerns around his uncontrolled diabetes and medication regimen.  

​

Background:

Francis’ primary care doctor had prescribed the following for his diabetes regimen:  

1. Metformin ER 500mg – 4 tablets (2000 mg) once daily 

2. Glipizide 10mg – 1 tablet (10mg) twice daily, 30 minutes before meals  

​

Patient Report:

The patient reported: 

• Often missing his second dose of glipizide as he forgets to take it sometimes  

• Not always taking glipizide before meals, more so whenever he remembered to take it  

• Expressed concern around self-monitored blood glucose values (SMBG) and most recent A1c, which had been >10%   

• SMBGs generally reported were above the recommended goals per the American Diabetes Association (ADA) guidelines – patient was using a traditional blood glucose meter:  

• Typically, >150 mg/dL fasting and >200 mg/dL two hours post prandial  

• Patient also reported difficulty around testing daily as it was painful to prick his fingers and had been hard to get a useable droplet size of blood  

• After the diabetes visit/follow up with his PCP, the patient reported that the focus of the visit was more diet-focused and minimal discussion around medication 

• Patient also stated that he was hoping to lose weight to help with his diabetes and overall health  

​

Physical Observation:

1. Patient appeared to be overweight and clearly upset about the uncontrolled diabetes to a point where it was starting to affect his motivation and mood  

2. Patient seemed overwhelmed with how much goes into diabetes care and did not know where to begin to help better control his condition  

3. He reported being more fatigued throughout the day for the last few months and wanted to learn how he could feel better and begin to control his diabetes  

​

Intervention:

Education:  

• The pharmacist/student interviewed and educated the patient about the importance of caring for himself holistically which included working on diet, physical activity, and getting on an appropriate medication regimen that works for him, while remaining adherent to the current regimen.  

• Motivational interviewing techniques were used and included ensuring the patient understood that they were not alone but rather well-supported through this process as his wife was present. The pharmacist also let him know that the pharmacy is committed to helping him with his goals.  

• Guideline-directed treatment for type 2 diabetes was discussed, and patient was educated on why certain therapies were used over others which then led to conduction of a diabetes-focused medication review. 

Comprehensive Medication Review: 

• Conducted a diabetes-focused comprehensive medication review in which medication adherence issues were identified (missing second daily dose of glipizide often due to forgetfulness).  

• The pharmacist stressed the importance of taking glipizide twice daily and before meals to get the most benefit. Additionally, the pharmacist discussed more effective diabetes medications based on the current evidence and guidelines. Patient was amenable to trying a different type of medication after being educated on additional benefits for cardiovascular health and weight loss potential.  

• Educated patient about risk of hypoglycemia with current medication and went over recognition/signs/symptoms and how to properly manage it if it does occur.  

• Educated on the importance of continuing to taking metformin 2000mg per day due to its many benefits and also ensured patient was taking correctly.  

• Reviewed patient’s SMBG/testing technique and found that patient was uncomfortable pricking his own fingers and has trouble getting an appropriately sized blood droplet for test strip.   

• Suggested and educated patient about continuous glucose monitors (CGMs) such as the Freestlye Libre® which can prevent some of the pain experienced with traditional blood glucose meters, and also allow for a larger snapshot of blood glucose levels.  

• Educated patient on importance of testing at appropriate times of day to ensure accurate blood glucose readings.  

Action Plan For Patient:  

• Continue taking metformin 4 tablets (2000mg) per day  

• Continue taking glipizide 10mg as prescribed (twice daily). Set a reminder on your phone when it is time to take your second dose of glipizide and try your best to take it BEFORE meals to get the most benefit from this medication.  

• Talk to your PCP about potentially trying alternative diabetes therapies that are favored more by current guidelines and have a lower risk of hypoglycemia and weight gain.  

• Talk to your primary care provider about potentially trying a continuous glucose monitor (CGM) to allow for better monitoring of blood glucose at home. In the meantime, wife will assist with blood glucose measuring twice daily and write the numbers down.  

Action Plan For Pharmacist/student:  

• With patient’s permission, reach out to their PCP to inform them that the pharmacy conducted a medication review with Francis in which the following was brought up:  

• Patient is concerned about medication regimen and is not compliant with current therapy.  

• Suggest a plan to decrease dose or discontinue glipizide due to the minimal benefit for patient, alongside issue of non-adherence.  

• Recommend the possible addition of a more preferred therapy as Francis was receptive to try a new medication that helps both diabetes and potential weight loss. Request prescription if appropriate.  

• Recommend the potential for Francis to try a CGM such as the Freestyle Libre® and request prescription if appropriate.  

• Set up a follow-up visit in 2 weeks to review any medication changes and educate patient accordingly.  

 

Outcomes of Care Provided:

Outcome 1: Patient was transitioned to a more guideline-directed and effective diabetes therapy of once weekly Trulicity and discontinuation of glipizide. 

• Patient’s PCP was amenable to pharmacist recommendation and sent a new prescription in for Trulicity® to be used once a week by subcutaneous injection.  

• Patient was educated by pharmacist once again on benefits, proper use, administration, possible side effects, and proper disposal.  

Outcome 2: Improvement in self-monitoring of blood glucose through initiation of Freestlye Libre® CGM for less painful and more effective blood glucose monitoring  

• Patient’s PCP was agreeable to pharmacist recommendation about trying a CGM. 

• Pharmacist educated patient on proper use and informed him that PCP can also monitor his blood glucose levels through online, shared provider platform.  

Outcome 3: Greater trust built between patient and pharmacist  

• With the time the pharmacist spent on helping Francis, he was very appreciative of the efforts taken by the pharmacy to help improve his diabetes care.  

• With the action items, Francis reported he was more motivated to take care of his diabetes and get it under control.  

• After about 3 months, Francis reported that his A1c dropped to ~8% (a 2 % decrease since the initial assessment) and was feeling much better health wise and less fatigued. He also lost some weight which he attributed to the Trulicity®.