S Palaian, A Chhetri, M Prabhu, S Rajan, P Shankar
counseling, diabetes mellitus, patient compliance
S Palaian, A Chhetri, M Prabhu, S Rajan, P Shankar. Role Of Pharmacist In Counseling Diabetes Patients. The Internet Journal of Pharmacology. 2004 Volume 4 Number 1.
In the last three decades role of pharmacist has changed dramatically. Presently, the pharmacists are becoming more patient oriented than product oriented. Patient counseling by pharmacist deals with providing information to the patients regarding the disease, medications and lifestyle modifications. It has been shown to improve therapeutic outcomes.
Diabetes mellitus is a group of metabolic disorders characterized by hyperglycemia and is associated with abnormalities in carbohydrate, fat and protein metabolism. The chronic complications may lead to microvascular, macrovascular, and neuropathic disorders. In diabetes, self management and patient adherence to the prescribed medication and lifestyle modifications is very essential and pharmacist can play an important role in counseling. The counseling plan should address the non-pharmacological and pharmacological measures. Education regarding the acute and chronic complications should be given. There is considerable evidence that Pharmacist provided counseling enhances the patient compliance and improves the quality of life outcomes in diabetes.
The role of pharmacist has changed dramatically over the past three decades. Traditionally pharmacists were viewed as individuals who dispensed medicine to the public. This role slowly got transferred into one which involved more of development of drugs. The later stage of 1960s revealed the growth of a new development that changed the concept of pharmacy from a product oriented to a patient focused one, called clinical pharmacy. Pharmacists are now becoming indispensable in monitoring patient drug therapy.1 The clinical pharmacy grew with the concept of pharmaceutical care, the responsible provision of drug therapy for the purpose of achieving definite outcomes which improve the patients' quality of life. It involves the pharmacist's decision to avoid, initiate, maintain, or discontinue drug therapy, both of prescription and non- prescription drugs. It is thus practiced in collaboration with patients, physicians, nurses, and other health care workers. The ultimate goal of pharmaceutical care is to optimize a patient's quality of life. These outcomes can be achieved by influencing the cure of the disease, elimination or reduction of symptoms, arresting or slowing the disease progress, prevention and diagnosis of disease or desired alterations in the physiological process.2
Patient counseling is an important means for achieving pharmaceutical care. It is defined as providing medication related information orally or in written form to the patients or their representatives, on topics like direction of use, advice on side effects, precautions, storage, diet and life style modifications.3 Patient counseling is interactive in nature and involves a one-to–one interaction between a pharmacist and a patient and/or caregiver. It should include an assessment of whether or not the information was received as intended and that the patient understands how to use the information to improve the probability of positive therapeutic outcomes.4 The ultimate goal of counseling is to provide information directed at encouraging safe and appropriate use of medications, thereby enhancing therapeutic outcomes.5 Several guidelines specify the points to be covered by the pharmacist while counseling the patients. 5,6
Diabetes: A Major Global Burden
Diabetes mellitus (DM) is a group of metabolic disorders characterized by hyperglycemia. It is associated with abnormalities in carbohydrate, fat and protein metabolism, and results in chronic complications including microvascular, macrovascular, and neuropathic disorders.7 The worldwide prevalence of DM has risen dramatically over the past two decades. It has been projected that the number of individuals with DM will continue to increase in the near future. Between 1976 and 1994, for example, the prevalence of DM among adults in the United States increased from 8.9% to 12.3%.8 Approximately 8 million Americans are known to have diabetes. Every year, on average 6,25,000 new cases of diabetes are diagnosed, and more than 178,000 deaths result from the disease and its related complications.9 Most cases of type 2 DM do not have a well- known cause; therefore it is uncertain whether it represents a few or many independent disorders manifesting as hyperglycemia.10
Diabetes has been implicated as the underlying cause of 12% of all new cases of legal blindness, over one third new cases of end- stage renal disease (ESRD), and nearly half of non traumatic lower – extremity amputations. Evidence has also shown that people with diabetes are two to four times more likely to die from heart disease or suffer stroke.8 Prevalence of diabetes in adults worldwide was estimated to be 4.0% in 1995 and expected to rise to 5.4% by the year 2025. It is higher in developed than in developing countries. 11
The number of adults with diabetes in the world is estimated to rise from 135 million in 1995 to 300 million in the year 2025. The major part of this numerical rise will occur in developing countries. There will be a 42% increase, from 51 to 72 million in the developed countries and a 170% increase, from 84 to 228 million in the developing countries. The countries with the largest number of people with diabetes are, and by the year 2025 will be India, China, and the US. Majority of diabetics are in the age range of 45- 64 years in the developing countries and ? 65 years in developed countries. This pattern will be accentuated by the year 2025, and diabetes will be increasingly concentrated in urban areas.11
Need for counseling in diabetes
Diabetes is a chronic, incurable condition that has considerable impact on the life of each individual patient. Patient involvement is paramount for the successful care of diabetes. The principal task of the health care team is to give each patient knowledge, self- confidence and support. Patients with diabetes and their families provide 95% of their care themselves,12,13 and, as a consequence, educational efforts to improve self- management are central components of any effective treatment plan.
The role of self-management behavior is clear even in studies that address relationships between pharmacologic treatment and outcomes at the physiologic level. For example, both the Diabetes Control and Complications Trial (DCCT) 14 and the United Kingdom Prospective Diabetes Study, (UKPDS)15 required patients to adhere to complex and intensive treatments over long periods of time. The primary goals of DM management are to reduce the risk for microvascular and macrovascular disease complications, to ameliorate symptoms, to reduce mortality, and to improve quality of life.16 Appropriate care requires goal setting for glycemia, blood pressure, and lipid levels, regular monitoring for diabetic complications, dietary and exercise modifications, appropriate medications, appropriate self monitoring of blood glucose (SMBG), and laboratory assessment of the aforementioned parameters.16
Studies have confirmed that the complications of diabetes can be reduced by proper control of blood glucose.15,17 The proper control is dependent on the patient's adherence to medications, life style modifications, frequent monitoring of blood glucose, etc and can be influenced by proper education and counseling of the patient.18 Pharmacists, being one of the indispensable members of the health care team, have an immense responsibility for counseling these patients.
Diabetes, if untreated, can lead to various complications such as neuropathy, nephropathy, retinopathy, hyperlipidema, diabetic foot ulcers, infections, etc.19 These complications adversely affect the quality of life of the patient. Quality of life is a multidimensional concept referring to a person's total well being, including his or her psychological, social, and physical health status.20 It is also well established that pharmacist provided patient counseling improves the quality of life of the diabetic patients.
Role of pharmacists in diabetes management
Because of the rapid expansion of available therapeutic agents to treat diabetes, the pharmacist's role in caring for diabetic patients has expanded. The pharmacist can educate the patients about the proper use of medication, screening for drug interactions, explain monitoring devices, and make recommendations for ancillary products and services.
The pharmacist, although not the health care professional to diagnose diabetes, is important in helping the patient maintain control of their disease. The pharmacist can monitor the patient's blood glucose levels and keep a track of it. During their contact, the patients can ask the pharmacist any questions they did not ask the physicians and can get further information regarding diabetes. The pharmacist can also counsel the patients regarding insulin administration regularly so that the onset of complications can be postponed by having tight glycemic control. Another important role of pharmacist is always being available to answer the questions of the patients. Overall, it is the pharmacist's role to help a diabetic patient in the best possible way to cope with their disease.21
Essential components of diabetic counseling
Since diabetes is a chronic complication affecting the diabetic patient at various levels, the counseling should focus on the nature of the disease, lifestyle modifications, medications, and acute and chronic complications.
Carbohydrates: The blood glucose level is closely affected by the carbohydrate intake. Daily intake should be kept fairly constant and the amount given should be appropriate to the level of physical activity. Most young people will require 180 g of carbohydrate per day, whereas 100 g may suffice for an elderly patient. If fiber rich food such as whole meal bread, jacket potatoes, etc. are eaten, then the carbohydrate content of the diet make up to 50% to 55% of the calories. People with diabetes should limit their sugar intake, but total exclusion of sugar from the diet is impractical and unnecessary.
Fat: Since there is an increased risk of death from coronary artery disease in diabetics, it is wise to restrict saturated fats and to substitute them with unsaturated fats. Furthermore, obesity is a major problem in diabetes, and fats contain more than twice the energy content per unit weight than either carbohydrate or proteins. More severe restrictions may be indicated for individuals with hypercholesterolemia.
Fiber: Dietary fiber has two useful properties. Firstly it is physically bulky and increases satiety. Secondly, fiber delays the digestion and absorption of complex carbohydrates, thereby minimizing hyperglycemia. For an average person with NIDDM, 15gm of soluble fiber (from fruits, pulses and vegetables) is likely to produce a 10% improvement in fasting blood glucose, glycated hemoglobin and low- density lipoprotein cholesterol.
A standard recommendation for diabetic patients, (as for nondiabetic individuals), is that exercise should include a proper warm-up and cool- down period. A warm up should consist of 5-10 min of aerobic activity (walking, cycling, etc.) at a low intensity level. The warm-up session is to prepare the skeletal muscles, heart, and lungs for progressive increase in exercise intensity. After a short warm- up, muscles should be gently stretched for another 5- 10 min. Primarily, the muscles used during the active exercise session should be stretched, but warming up all muscle groups is optimal. The active warm up can either take place before or after stretching. Following the activity session, a cool-down should be structured similarly to the warm-up. The cool- down should last about 5- 10 min and gradually bring the heart rate down to its pre- exercise level.23
The patient should be cautioned not to skip meals at any time and to follow regular eating patterns to prevent hypoglycemia. OHAs are comparatively safe drugs. However some patients may develop loss of appetite, nausea and vomiting, abdominal pain, cramps, malaise, diarrhea or weight loss. The counseling points for individual OHAs are listed in the table 1.
Hypoglycemia is caused by taking too much of certain diabetic medicines, missing a meal or delaying a meal, exercising more than usual, or drinking alcohol. The symptoms can be classified as initial, intermediate and advanced symptoms. Initial symptoms may start with sweating, tremulousness, nausea and vomiting, dizziness, mood change, hunger, weakness and progress to the intermediate symptoms of confusion, poor coordination, headache and double vision. The advanced symptoms are unconsciousness and seizures.
The management of hypoglycemia includes taking half a cup of any fruit juice, 2 or 3 glucose tablets, 2 tablespoons raisins, 1 or 2 teaspoons of sugar or honey, half cup of regular soft drink or liquid concentrated glucose. For advanced hypoglycemia, medical intervention is needed with glucagon 1 mg subcutaneously or intramuscularly.24
Hypoglycemia can largely be prevented by taking antidiabetic medications properly, eating regular meals, and regular checking of blood glucose. Table 3 lists the summary of counseling points for preventing hypoglycemia.
The risk factors include extremes of age, poor glycemic control, poor socioeconomic status, non-compliance etc. In general, insulin omission or non-compliance is identified as an important contributing factor for development of DKA. 25 The pharmacist can counsel the patients regarding the strategies to prevent the occurrence of DKA.
Diabetic neuropathy: It is characterized by nerve damage caused by chronic high blood glucose levels. Neuropathy can lead to loss of pain or touch sensations on the feet. It can also cause pain in legs, arms or hands. Nerve damage can progress slowly and most of the time the patients may not even be aware that they have nerve problems. Hence regular check ups to rule out diabetic neuropathy is essential. For prevention of diabetic neuropathy the blood glucose and blood pressure should be kept as close to normal as possible. The other precautions include stopping/limiting alcohol intake, regular checking of feet every day and quitting the smoking.
Diabetic retinopathy: Retinopathy is a disorder of the eye that occurs in majority of the adults with diabetes. The patient suffering from retinopathy may complain of blurring of vision, seeing black spots, flashing lights etc. Once detected proper treatment of diabetes can reduce the progression of retinopathy.
Diabetic nephropathy: Nephropathy (disorder of the kidney) is one of the potential life threatening complications of diabetes. Poor control of diabetes is associated with enlargement of the kidneys and impairment in their function. The development and progression of nephropathy in diabetics can be delayed by tight glycemic control.
Infections: Many infections are seen commonly in diabetic patients. This is an indication of poor diabetes control. Infections at mild stages, if not treated, can lead to life threatening sepsis in these patients.
Elderly: Elderly diabetic patients usually have various other comorbid conditions like hypertension, hyperlipidemia etc. They may also have some degree of psychiatric imbalance. The counseling in these patients should also address the emotional impairment due to diabetes.
Children: Children, especially the type-1 diabetes patients, require several special precautions. In addition to other essential counseling points, the pharmacist should also focus on the administration time of insulin during school days, storage of insulin in the school, risk of hypoglycemia while playing etc.
Pregnancy: Since elevated blood glucose is associated with congenital abnormalities, the pregnant patients should be asked to have strict control over the blood glucose.
Multiple disorders: Patients with multiple diseases need special counseling for those diseases other than diabetes. Patients with underlying cardiac problems should be cautioned that they may not experience pain during MI and hence should be advised to have regular cardiac checkup.
Frequent traveling: Diabetes patients who travel frequently should be advised regarding the use of insulin pen. They should be also counseled regarding the importance of food plan during their journey and the possibility of hypoglycemia. They should be warned not to neglect even a simple infection as it may turnout to be fatal.
Dry feet well, also between the toes
Keep the skin supple with a moisturizing lotion
Use soft socks or stockings, which must neither be too big nor too small
Never walk barefoot- neither indoors nor outdoors
Examine the shoes every day for cracks, pebbles, nails and other irregularities which may irritate the skin
A brisk walk everyday stimulates the circulation and makes the patient feel much better.
Strategies to improve counseling in diabetes patients
Since diabetes is a chronic illness and the diabetic patients also suffer from varying degree of cognition impairment, special strategies should be adopted for effective counseling. Some of which are discussed below.
Evidence for beneficial effects of pharmacist provided counseling in diabetes
Several studies have acknowledged the importance of pharmacist provided counseling in diabetes patients.
The Fremantle Diabetes Study examined the effect of a 12-month pharmaceutical care (PC) program on vascular risk in type 2 diabetes. In this study patients were randomized to PC or usual care. PC patients had face-to-face goal-directed medication and lifestyle counseling at baseline and at 6 and 12 months plus 6-weekly telephone assessments and provision of other educational material. The main outcome measure was change in HbA(1c). The study concluded that the 12-month PC program in type 2 diabetes reduced glycemia and blood pressure. Pharmacist involvement contributed to improvement in HbA (1c) independently of pharmacotherapeutic changes. 28
Cioffi et al conducted the study to determine the effect of a clinical pharmacist-directed diabetes management clinic on glycemic control and cardiovascular and renal parameters in patients with type 2 diabetes. The primary endpoint was the impact of 9-12 months of participation in the clinic on HbA1C. The study demonstrated that a clinical pharmacist can effectively care for patients with diabetes referred by their primary care provider because of poor glycemic control. 29
Gerber et al conducted a study to assess the impact on healthcare utilization and costs of pharmacist consultations provided to patients with diabetes. The study suggested that pharmacist consultations provided to patients with diabetes can decrease total healthcare costs in a health maintenance organization. 30
Cranor et al assessed the persistence of outcomes for up to 5 years following the initiation of community-based pharmaceutical care services (PCS) for patients with diabetes. A Quasi-experimental, longitudinal pre-post cohort study was conducted in twelve community pharmacies in Asheville, N.C. The study concluded that patients with diabetes who received ongoing PCS maintained improvement in HbA1c over time, and employers experienced a decline in mean total direct medical costs. 31
The impact of a specially designed patient education program upon the diabetes-related knowledge and compliance of insulin dependent diabetic patients was investigated by Powell et al. The program was successful in producing improvements in both knowledge and compliance but a need for individualization of patient education efforts was indicated. 32
Odegard et al evaluated the effect of a pharmacist intervention on improving diabetes control; secondary endpoints were medication appropriateness and self-reported adherence. Seventy-seven subjects, were randomized to receive a pharmacist intervention (n = 43) or usual care (n = 34) for 6 months, followed by a 6-month usual-care observation period for both groups. The study concluded that pharmacist intervention did not significantly improve diabetes control, but did allow for similar HbA (1c) control with fewer physician visits. Medication appropriateness and self-reported adherence compared with usual care in individuals with poorly controlled diabetes were not changed. 33
Kiel and McCord evaluated the changes in clinical outcomes for patients enrolled in a pharmacist-coordinated diabetes management program. Data collection included baseline and follow-up values for HbA1c and lipids as well as frequency of adherence to preventive care, including annual foot and eye examinations and daily aspirin therapy. The study concluded that the pharmacist-coordinated diabetes management program was effective in improving clinical markers for enrolled patients. Significant improvements were observed in Hb A1C and LDL values as well as the frequency of adherence to preventive care.34
Diabetes is a chronic illness that requires a combination of pharmacological and non-pharmacological measures for better control. Patient adherence to medication and lifestyle modifications plays an important role in diabetes management. Pharmacists being an important member of the healthcare system have an immense responsibility in counseling these patients. To be an effective counselor, the pharmacist should update his knowledge regarding the latest developments and should possess adequate verbal and non-verbal communication skills.
Subish Palaian Lecturer, Department of Pharmacology Manipal Teaching Hospital / Manipal College of Medical Sciences Pokhara, Nepal E-mail: email@example.com Phone: +977 61 526416 Extn: 221