Drug-Related Problems

Today's pharmaceuticals and advanced medical technologies provide many therapeutic options for treating diabetes and its comorbidities. If used inappropriately, however, they can cause serious illness, long-term disability, or even death. A study released in February 2001 shows that misuse of prescription drugs in the United States costs $177 billion annually in additional treatments, hospital care, and doctor visits, up from $76.5 billion in 1995. The study estimates that, more importantly than the costs, 218,000 annual prescription-drug-related deaths are due to misused prescription medications.³² The study identifies several categories of drug-related problems: improper drug choice, underdosage, overdosage, adverse drug reactions, drug interactions, and undertreatment. Additional identified factors include untreated medical conditions and medication use with no indication.^33,34 More than 50 percent of individuals who have chronic disorders do not take their medication properly. Over 60 percent of persons with diabetes do not adequately control their blood glucose. Of those persons being treated for high blood pressure and high cholesterol, 65 percent and 49 percent, respectively, are not able to reach target blood pressure and total cholesterol levels.³⁵ To improve compliance and minimize these health care adversities, medication therapy regimens must be consistently and carefully monitored. Correct use of medication improves individuals' health and saves money for the health care system.^36,37,38

Strategies for Managing Drug Therapy

People with diabetes should establish a relationship with a pharmacist who can help monitor drug regimens, advise how to take medications properly, and provide other information to help them control their diabetes. Strategies include the following:

• Use of medications. Individualize drug regimens to determine the best time to take medications to reduce side effects and drug interactions. Offer behavior strategies, compliance aids, appropriate dosage forms, and drug delivery systems.
• Monitoring treatment. Support treatment plans by monitoring for adverse effects and medication effectiveness. As part of the collaborative care plan with other health care providers, monitor the ABCs between regular physician or clinic visits. Provide referrals, as needed, for reevaluation and treatment.
• Self treatment and OTC medications. Ask people with diabetes if they are using nonprescription medications; vitamin, herbal, and nutritional supplements; or topical and skin care products. Assess the severity and urgency of the person's complaint, the appropriateness for self treatment, and any cautions and contraindications. Recommend self treatment, follow up, and/or a referral to another health care professional, as appropriate.
• Selecting and using a blood glucose meter. Help the person choose an appropriate blood glucose meter and provide training on how to use it. Educate the person about the results, actions to take, and when to seek help. Self monitoring blood glucose (SMBG) is an important way to assess the effectiveness of therapy.
• Cost control. Advise on ways to decrease costs of medications and supplies by providing information on private insurance plans, prescription drug programs, Medicare and Medicaid, the role of generic medications, and possible coverage for referrals to other health care providers.

Coordination of Care

Coordination of care presents many challenges when delivered by multiple providers in a variety of settings. Changes in drug therapy may occur when patients see specialty providers or during acute illness or hospitalization. When there are issues of multiple disease states and multiple drugs, along with the use of OTC drugs, herbal products, and other supplements, diligent case management is required to ensure continuity of care that is well coordinated.

As an extension of the dispensing role of pharmacists, central medication review and drug therapy management (including nonprescription products) can ensure that a current drug therapy plan is appropriately implemented. In one study, collaborative drug therapy management (CDTM), provided by pharmacists in collaboration with other health care providers, resulted in identification of problems in 65 percent of individuals' drug regimens.³⁹ In other studies, CDTM resulted in decreased morbidity and mortality, as well as decreased costs attributable to fewer un-scheduled physician visits, urgent care visits, emergency room visits, and hospital days.^40,41,42

With coordinated care, all members of the health care team, including the person treated, benefit from having a primary resource to deliver intended drug therapy, information, and monitoring for effectiveness and adverse effects. This coordination will help ensure adherence to the intended treatment plan and identify drug and disease management issues in a timely manner.