Clinic Focuses on Tough-To-Treat Diabetes

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ORLANDO, Fla.—Patients with type 2 diabetes who have inadequate glycemic control can benefit from a Diabetes Intense Medical Management (DIMM) Clinic, where they are managed by a clinical pharmacist who is also a certified diabetes educator (CDE) and works under the supervision of an endocrinologist, researchers reported here at the 70th Scientific Sessions of the American Diabetes Association.

In May 2009, a DIMM Clinic involving collaboration between a CDE-trained pharmacist and an endocrinologist was set up at the Veterans Affairs San Diego Health System. A key goal of the clinic is to help type 2 diabetes patients achieve metabolic targets, including diabetes, lipids, and hypertension.

The clinic, which is held once a week for a half a day, combines clinical care with patient-specific diabetes education to develop an individualized treatment plan.

Results at six months showed that nearly three-quarters of patients had achieved a target hemoglobin A1C (HbA1c) below 9%.

“Of the nearly 10,000 patients with diabetes who are part of our local Veterans Affairs health care system, the majority have an HbA1C above the ADA-recommended target,” said Candis M. Morello, PharmD, CDE, FCSHP, Associate Professor of Clinical Pharmacy at the University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, and an Ambulatory Care Pharmacist Specialist at the Veterans Affairs San Diego Health System.

Patients are referred by their primary care physician to the DIMM Clinic, where they are initially evaluated by an endocrinologist and pharmacist. Then, they are cared for by the pharmacist until they have met their personal HbA1C goal, usually an HbA1C below 7%, which typically takes about six to nine months. Once patients have achieved all metabolic goals, they are referred back to their primary care providers.

Morello, who is the CDE-trained pharmacist managing diabetes patients in the Veterans Affairs San Diego Health System DIMM Clinic, also has prescribing privileges at this medical center.

Patients return to the DIMM Clinic every two to three months to have their diabetes-related pharmacotherapy assessed and their blood pressure and lipids evaluated. During their clinic visits, patients also undergo foot examinations.

The pharmacist also teaches patients about diabetes control, complications, diet, exercise, hypoglycemia treatment, self-monitoring of blood glucose, and pattern management.

Morello and her colleagues presented data in 21 patients who have been followed for up to six months. In their study, the primary outcome measure was the mean change in HbA1C. Their data showed that the mean baseline HbA1c of 10.7% decreased significantly to 8.6% at three months and 8.0% at six months. 

By six months, more than 70% of patients had an HbA1c below 9% and nearly 40% had an HbA1c less than 7%.

The researchers observed statistically significant reductions in fasting plasma glucose, total glucose, and triglycerides. The group experienced a slight increase in mean BMI, which is typically seen with increased glucose control.

While emphasizing that the results are preliminary, Morello said that she believes that her additional training as a CDE is a major contributor to the impressive results seen thus far.

“I think that being a CDE has been useful in helping patients achieve their goals,” she said. “When I explain to patients why they need to achieve their goals as well as how to achieve their goals, they seem to be more motivated to take control of their diabetes.”

She also emphasized that the CDE-trained pharmacist does not replace the primary care physician. “I typically contact the primary care doctor if, for example, the patient is suddenly dehydrated or has signs of a urinary infection, and the primary care doctor can then perform a work-up.” 

Finally, Morello noted that the DIMM Clinic provides benefits for the primary care physician beyond helping patients satisfy their metabolic goals. “By taking charge of the patients' glycemic and other metabolic abnormalities, our program ‘frees up' the primary care doctor to focus on other medical problems the patient might have such as rheumatoid arthritis or osteoporosis,” she said.

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