Diabetes can be a complicated condition to manage; however, the vast majority of diabetic conditions are managing other illnesses, as well—by some estimates, as many as 40%t of diabetic patients have three additional comorbid conditions. Mandy Reece, PharmD, CDE, BC-ADM, BCACP, FAADE, vice chair and associate professor of pharmacy practice at the Philadelphia College of Osteopathic Medicine School of Pharmacy, offered insight into the way pharmacists should help patients balance these additional concerns.

What are the important considerations for pharmacists working with patients with diabetes who also have other conditions?

Pharmacists in the community setting are in an ideal position as they know all the medications that a patient is taking, whether primary care or specialist provider has written the prescription. The most important consideration begins by carefully listening to the patient as they share their concerns and priorities for health and wellness. Working with the patient to address concerns such as cost and potential adverse effects of medications, and making sure their no medication related problems, are the major considerations for working with this population of patients. Additionally, pharmacists must consider their role in making sure medications do to not interfere with patient’s comorbidities or whether dose adjustment is needed when person develops a comorbidity.  

Pharmacist talking with diabetes patient about comorbidities. Source: Getty

Which conditions are the most challenging to treat in patients who also have diabetes, and how do the required medications interact with efforts to manage blood sugar levels?

Psychiatric conditions such as major depressive disorder, bipolar, schizophrenia are challenging as the medications can create insulin resistance. HIV is a particularly challenging condition, as the anti-retroviral medications, particularly the protease inhibitors, have potential to enhance insulin resistance already present in type 2 diabetes. End stage renal disease and severe renal impairment limit the potential medications for use in type 2 diabetes as many of the medications are eliminated renally.  

Hepatic disease such as NASD, Hepatitis C and cirrhosis create dysfunction of glucose regulation leading to excessive hepatic glucose production.  

Are there particular demographic groups that require specific attention to co-morbid conditions? Why, and how is their care different?

Older adults (60 years of age and older) require special attention due to age related physiologic changes (changes in gait and loss of muscle mass) and development of co-morbidities such as cardiovascular events and renal impairment. For elderly patients with long history of diabetes, the risk of complications and comorbidities increases significantly, so monitoring for complications and adjustment of medication therapy due to comorbidities is required.

Pregnant patients with preexisting diabetes require special monitoring for complications (especially retinopathy), adjustment of medications for chronic hypertension and dietary changes instead of medications for dyslipidemia [abnormally elevated fats in the blood]. Blood pressure and blood glucose must be monitored carefully due to potential maternal and fetal complications.

Lastly, underserved populations require close monitoring and management of comorbidities, as lack of transportation, limited financial resources, and health illiteracy create significant barriers for these populations. Diabetes education as well as education on their comorbidities are vital for this group so they need to have an understanding of their disease conditions and how to manage them. Monitoring for complications and comorbidities (i.e. heart disease) is key so that early intervention is provided.  

What is the pharmacist role in monitoring patients with diabetes for the development of any new co-morbid conditions?

The focus here is really around the pharmacist engaging with the patient to ensure they understand common complications and comorbidities associated with diabetes. To begin, the pharmacist needs to assess what baseline knowledge the person with diabetes has, then discuss why these complications and comorbidities are important. At this point, it would be appropriate to discuss monitoring tests (specific tests, location of testing and frequency) as well as community resources available to assist if financial resources are limited.  Lastly, the conversation can turn to highlight the signs and symptoms, and treatment of complications and comorbidities. To close the conversation, asking the patient to summarize the information provided and identify any knowledge gaps or concerns would be ideal. Periodic reminders of potential complications and comorbid conditions can be helpful.