With an intimate understanding of how medications work, and patient care training to match, clinical pharmacists bring a unique and valuable perspective to diabetes care. Samuel Grossman, BS Pharm, PharmD, CDE discusses the significant and evolving role they play in patient management as the prevalence of diabetes grows.
By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net
Many people when they think of pharmacists, they think of their friendly, knowledgeable community medical specialist who dispenses medications and doles out advice to everyone in need of it. What many people may not realize is that this traditional role is expanding especially in the chronic disease continuum with these medical specialists taking on greater responsibilities including caring for patients and prescribing medicines and helping them manage their conditions.
In today’s medical environment, costs are spiraling out of control, chronic diseases such as diabetes are growing in their greatest prevalence ever, and a looming shortage of primary care physicians is on the horizon in the 21st century.
With these factors as part of the clinical care backdrop, pharmacists are poised to step in and aid in these challenges. 
For starters, today’s pharmacy students come out of school with a doctorate in clinical pharmacology which not only pertains to the study of medicine but the study of physiology as part of their training.
In addition, the passing of the Collaborative Drug Therapy Management (CDTM) laws in the majority of U.S. states provides pharmacists with more latitude in medically managing patients. Specifically, CDTM gives pharmacists the right to implement, monitor, and modify drug therapy as described by written protocols with oversight from physicians.
As a clinical pharmacist and diabetes educator at the Department of Veterans Affairs (VA) in New York, Samuel Grossman, BS Pharm, PharmD, CDE, manages diabetes patients, including showing them how to administer insulin or take other medications, and counsels them on diet and exercise. He also consults with physicians on areas such as proper medication dosing at the VA.

In addition to his duties at the VA, Dr. Grossman is an adjunct associate professor at Hunter-Bellevue School of Nursing of the City University of New York and a clinical assistant professor of pharmacy at Arnold & Marie Schwartz College of Pharmacy of Long Island University. He is also the past-president of the Garden State Association of Diabetes Educators and is a member of the Diabetes Advisory Board to the Commissioner of Health and Senior Services of the state of New Jersey. He is president of Diabetes Care On-The-Go, Inc., a diabetes education center in Brooklyn, New York.
Dr. Grossman (below, right) began his interest in clinical diabetes care after watching his father grapple with type 2 diabetes. He witnessed how it affected not only his father’s lifestyle, but how it affected everyone in his family. In coming to terms with his father’s condition, Dr. Grossman decided one of his areas of focus in clinical care would be to specialize in treating patients with pre-diabetes and metabolic syndrome. Dr. Grossman felt taking a preventive management approach was the optimal way to address these pre-disease states and possibly reverse peoples’ conditions before progressing to type 2 diabetes and the more permanent lifestyle changes, and likely having to contend with complications.
Dr. Grossman believes pharmacists have an opportunity to play an important role in what he says is one of the biggest missing components to care in clinical settings today: patient comprehension of medications. Understanding there is a lot to cover in the course of a medical appointment and a limited amount of time in which to do so, physicians may not go over every detail as to why patients are being prescribed multiple medications and what mechanisms of action each medication is meant to do.
He explains that clinical pharmacists are not expected to take on the patient load physicians typically do, so pharmacists can take the time to explain medications to patients, and give them a deeper understanding of how they work on the body. In addition, clinical pharmacists can help patients to achieve disease management goals, and provide support to a patient base often burdened with multiple co-morbidities. In this regard, pharmacists may be well-suited to help co-manage patients with physicians, like in patient-centered medical home settings where a team of medical personnel manage individual patients. 
DiabetesCare.net talked with Dr. Grossman about the special skill sets pharmacists bring to the table, their evolving role in diabetes care, and how to view the newer generation of medicines for treatment of type 2 diabetes.    
DiabetesCare.net: What are the most significant skills clinical pharmacists bring to clinical care that can help patients with diabetes?
Dr. Grossman: Everyone who is in school right now becomes a doctor of pharmacy. Years ago, there was no such accreditation. For those pharmacists who have a bachelor’s of science (BS) in the specialty, their education and training is not as extensive, particularly not having courses in pharmacokinetics and pharmacodynamics. With these particular subjects, you learn how the body and medications interact. Particularly, the affect of the medication on the body and the affect of the body on the medication. 

For these reasons, some pharmacists with BS degrees have returned to school to obtain a doctorate degree. For many professionals with BS degrees in pharmacy or doctorate degrees in clinical pharmacy there is also a need for additional training to become diabetes educators.
For example, patients often have co-morbidities and pharmacists with training have the ability to decipher which co-morbidity can affect a specific medication and possibly say, ‘this medication is not only going to be ineffective it is going to be toxic.’ This can be especially important in diabetes care where patients often have multiple medications and numerous co-morbidities.   
DiabetesCare.net: Conversely, what are the biggest challenges clinical pharmacists face in delivering diabetes care?
Dr. Grossman: The American lifestyle is a problem for us. This can be found in patients’ behaviors including their diets, lack of exercise, and medication noncompliance--which might lead to overall medication therapies not being as effective.
For example, a clinical pharmacist can look at a patient with diabetes who is suffering both renal failure and liver dysfunction and give the patient the appropriate medications and dosage, but six months later the desired effect is not achieved. If the patient hasn’t changed his lifestyle, his medications are not going to be as effective continue to work. If you have high sugar levels and you continue eating foods like white rice or pasta, these medications will not be as effective.  
Patient adherence to medications can be problematic if patients don’t stay up on things. Some patients might complain they cannot afford their medications. The expense of medications and supplies is yet another challenge.
The new therapies have shown to be very expensive, and in today’s economy where people are looking for ways to conserve, it is difficult to tell patients this medication is good for you, and you know the patient’s co-pay is quite high, and they are choosing between their medications and some other necessities.
DiabetesCare.net: There are some who criticize the number of medications people with type 2 diabetes take as part of their daily regimen, claiming many of them are prescribed too much for their diabetes management, and not enough emphasis is place on items such as diet and exercise. What is your take on the modern medical care in terms of medicines being prescribed versus nutrition, exercise, and behavior change?
Dr. Grossman: Sometimes patients feel they are being prescribed a very high dose or have too many medications, but what they don’t seem to realize is that when patients don’t want to go on insulin, providers must make adjustments in medication dosages. They might have to give much higher doses to get the maximum benefit of a specific medication.
Other times, a provider is dealing with a patient who has a co-morbidity such as renal dysfunction, and in order to get the maximum effect without toxicity, the provider prescribes three medications each with their own mechanism of action. Yet, patients don’t realize these existing health issues play a role in why they have more medicines. This is often left out in conversations with patients.
Another issue is that patients don’t realize their sugars are too high on a regular basis. Patients need to understand it is not about burdening them, but offsetting the effects of specific medications or fighting high blood sugars. Ultimately, if the glucose remains high, there will be complications.
The provider also needs to explain why they are prescribing multiple medications, and in today’s clinical care environment, providers are pressed for time.

DiabetesCare.net: There is a whole class of pharmaceuticals, specifically the glucagon-like peptide-1 analogs (GLP-1s) for treatment of type 2 diabetes which are showing to be beneficial. There are a couple in particular with the potential beneficial side effect of weight loss. What is your take on this category of medicines, and what do you think of this particular time overall in diabetes care in terms of pharmaceutical treatments for patients?

Dr. Grossman: I feel the weight loss that is expected from these medications can be further achieved if the patient maintains and improves lifestyle modifications that includes diet and exercise.

What we have to understand is that the GLP-1 analogs through their actions in the body make the patient feel full. Therefore, the patient doesn’t eat as much and that is why weight loss occurs.

Generally speaking, many of my patients eat because it makes them feel good or because it is socially acceptable to eat larger quantities. In these patients, you don’t see any weight loss. We have seen that people can have significant weight loss when they take these medications and they adhere to stricter diet and exercise recommendations.

Overall, the GLP analogues and DPP inhibitors are great medications. For starters, they don’t cause as much hypoglycemia, and thus patients can tolerate them better. They also reduce post-glycemic excursions, so the sugar levels after meals are being reduced because these medications slow the release of glucagon from alpha cells. Many of my patients are seeing benefits with these medications. 

Another benefit is that these medications that affect the incretin hormones are not insulin. Although some of these products are injectable, patients just do not want to be on insulin. 
DiabetesCare.net: Understanding that New York State just passed a Collaborative Drug Therapy Management (CDTM) law last spring, what is you take on CDTM thus far and how does it help clinical pharmacists in diabetes care?
Dr. Grossman: The law is very beneficial to pharmacists and patients. It gives pharmacists recognition for their actions. Pharmacists are the medication experts. People can go into pharmacies and don’t need to make an appointment and they can see their pharmacists and get educated about everything from insulin usage to how to store medications--and that’s an opportunity for education. And educational opportunities come all the time now that the recognition is there. The pharmacist can now get reimbursed for education services and they can spend more time with patients who are learning how much medication they should be taking as well as other diabetes self-management skills.
DiabetesCare.net: In thinking about the future, where do you see clinical pharmacists going with regards to diabetes care?
Dr. Grossman: I believe pharmacists are going to be very involved in diabetes care. What I’m seeing is more education-based and consulting opportunities, and I think they will partner with diabetes care centers.

I also see them in collaborative settings like the patient-centered medical home model, where different providers including nurses, social workers, dietitians, and pharmacists work together in treating patients as a team. This way, patients will be well-cared for, have well-rounded information, and continuous communication from their health team. Pharmacists will be part of the model to improve patient management--whether it is in their pharmacies, hospital settings, or clinics--educating patients and monitoring their care.

Dr. Grossman is a contributing member of DiabetesCare.net with our Ask the Professionals feature. Anyone who has a question about diabetes medicines or insulin-therapy, can go here to ask Dr. Grossman a question. This is a free service! Come check out his latest Medicine Cabinet column as well.