Pharmacist Intervention for Glycemic Control in The Community
Pharmacist Intervention for Glycemic Control in The Community
Background: Approximately 1.9 million Canadians are living with diabetes and this is
 estimated to increase by 75% over the next few decades. Pharmacists are front line primary
 healthcare professionals who see patients with diabetes frequently and in Alberta, they have
 been allowed to prescribe medications and order laboratory tests. As such, pharmacists could
 systematically identify poorly controlled diabetes patients and provide greater access to
 diabetes interventions to improve blood sugar control.

 Objective: The aim of this study is to determine the effect of a community pharmacist
 intervention on blood sugar control in individuals with poorly controlled diabetes.

 Project description:

 100 adults with type 2 diabetes and uncontrolled blood sugar will be defined by the
 participating pharmacists. Blood sugar control is going to assessed using hemoglobin A1c test
 (a blood test to measure individual's blood sugar control over the last 3 months). This test
 requires obtaining a blood spot from the patient which will be obtained by pricking his/her
 fingertip. Based on the hemoglobin A1c test result the pharmacist will assess the patient's
 need for insulin glargine, if the patient needs insulin glargine the pharmacist is going to
 prescribe it for him/her and educate him/her on its use. Patients are going to be followed up
 closely by the pharmacists for 6 months with regular updates to the patients' family
 physicians. This multi-centre study should demonstrate pharmacists' ability to improve
 glycemic control and improve access to care.
BACKGROUND/RATIONALE:

 Approximately 1.9 million Canadians are living with diabetes. Estimates are that this number
 will increase by 75% over the next few decades. Glycemic control in patients with type 2
 diabetes mellitus is poor, and poorly controlled patients contribute significantly to the
 cost of primary health care in Canada. 10% of all acute care hospital admissions in 2006 were
 attributed to diabetes and its complications.

 As type 2 diabetes is a progressive disease, most patients with type 2 diabetes will
 eventually require insulin. In patients who present with type 2 diabetes and a HbA1C over 9%,
 insulin can be started immediately, however, historically physicians generally perceive their
 to be patient difficulties in starting insulin therapy.

 INSIGHT demonstrated improved glycemic control with addition of insulin glargine to oral
 hypoglycemic agents in patients with type 2 diabetes. However, physicians are often reluctant
 to initiate insulin in these patients. In addition, physicians do not have a system to
 systematically identify potential candidates for insulin add-on therapy

 Pharmacists are front line primary care professionals who see patients with diabetes more
 frequently than family physicians and as such, could systematically and proactively identify
 patients with type 2 diabetes with poor glycemic control as a public health approach to
 chronic disease management. This approach has been used successfully by our group in the past
 with dyslipidemia and hypertension management involving patients with diabetes.

 The scope of practice for pharmacists is changing, with legislation in Alberta (and soon
 other provinces) allowing pharmacists to prescribe Schedule I medications and order
 laboratory tests. As such, there is an opportunity to provide greater access, convenience and
 improved glycemic control by engaging community pharmacists and their patients.

 PRIMARY OBJECTIVE: To determine the effect of a community pharmacist prescribing intervention
 on glycemic control in patients with poorly controlled type 2 diabetes.

 SECONDARY OBJECTIVES:

 -  To determine the effects of pharmacist-directed diabetes care focusing on glycemic
 control on:

 -  patient satisfaction

 -  quality of life

 -  dosage changes of oral agents

 -  persistence on insulin glargine and the end of follow-up

 -  hypoglycemic episodes

 -  To conduct a health economic assessment of the costs and benefits of the intervention

 METHODS:

 Design: multicentre pragmatic before-after design trial

 Setting: Ten community pharmacies in Alberta for recruitment and follow-up, engaging both
 patients and family physicians

 • participating pharmacists will have additional prescribing authorization. For pharmacists
 not having additional prescribing authorization, we will facilitate their application as done
 in the rural RxACTION study.

 Recruitment: Pharmacists will systematically identify potential candidates by inviting all
 patients with type 2 diabetes receiving oral hypoglycemic medications to check their HbA1c
 using a point of care test. HbA1c is going to be measured in the pharmacy. The patient has to
 sign the first stage consent form in order to get his/her HbA1c measured. After signing the
 consent form, the patient's HbA1c will be measured using a digital meter which requires a
 blood spot which will be gained by pricking the patient's fingertip. If the result of HbA1c
 test is normal the patient will be given his/her result and told to keep up the good work. If
 the result of HbA1c test is high (7.5-11 %) and the patient meets the other inclusion
 criteria for the study the patient will be asked if he/she wants to participate in the study.
 If the patient agrees on participating in the study he/she will be asked to sign the second
 stage consent form. After signing the consent form the patient will be started on insulin
 glargine at bedtime and will be taught how to use the insulin pen. If HbA1c is > 11% the
 patient will be assessed by the study investigators, treatment recommendations will be
 checked and will be referred to his/her family physician.

 Follow-up: Patients will be followed at 2, 4, 8, 14, 20, and 26 weeks to capture adverse
 events, adherence to the insulin regimen, fasting blood sugars (measured by the patient),
 insulin dose and titration. HbA1c will be measured at baseline and then at week 14 visit and
 week 26. Interim telephone follow-up may be performed at the discretion of the pharmacist
 investigator, however telephone follow-up cannot be used for 2 consecutive visits, nor for
 week 14 or 26 visits. Fasting glucose will be measured at the discretion of the pharmacist
 and patients will monitor their blood glucose at home and record in a standard patient diary.

 After each follow up study the pharmacists is going to inform the patient's family physician
 if there were any changes in the patient's treatment regimen and also about the results of
 any tests conducted.

 One year after the final follow up visit, the pharmacy is going to receive a phone call from
 the study investigators to check if the patient is still taking insulin.
Inclusion Criteria:

 -  Male or Female over 18 years of age

 -  Type 2 diabetes for at least 6 months

 -  Taking 1 or more oral hypoglycemic agents

 -  Patient attending your community pharmacy where you decided that addition of insulin
 glargine may be of benefit to the patient

 -  Baseline HbA1c 7.5 - 11%

 -  Signed informed consent

 Exclusion Criteria:

 -  Have used, or currently using, Insulin

 -  History of ketoacidosis

 -  Pregnant

 -  Works night shift

 -  Renal impairment(Serum Creatinine: females ≥ 124 mmol/l, males ≥ 133 mmol/l)

 -  Clinically unstable

 -  Unwilling/unable to attend follow up visits

 -  Unlikely to adhere to study procedures (eg. due to cognitive limitations, severe
 psychiatric disorder or alcoholism)