Quality of life pharmacists V1 16 10 19 – Copy

Table of Contents

The Wheel of Epidemiological TransitionThe period of last there decades in the Indian subcontinent witnessed an epidemiological transitionfrom infectious and vector-mediated diseases to chronic metabolic diseases which his evident from themarked rise in morbidity and a conspicuous fall in mortality. 1 This could be attributed to the quantityand quality of health services along with their distribution and organization. 2 The evolution ofantibiotics, antimicrobial agents, insecticides and vaccines in parallel to the improved diagnostic andtherapeutic technologies, comprise the twentieth century’s technological developments and innovationswhich made distinctive a progress in the effective management and control along with the prevention ofmany infectious diseases. One of its starling triumphs lies in the eradication of smallpox. 2Thus, a distinctive escalation of chronic degenerative diseases and a parallel reduction of the infectiousdiseases is observed with which began to generate a pattern of gradual epidemiological transition. 2 Theimpact of these c hronic medical conditions can delve to impact in multiple dimensions of Health-Related Quality Of Life (HRQOL). Diabetes is one such chronic medical condition which welcomesmetabolic syndromes along with its complications with a red carpet if kept unchecked. 3 The Bane of Diabetes This serious chronic disease occurs either there is a reduced insulin production by the pancreas or thereis an inability to effectively utilize the insulin produced. The increased global prevalence (4.7% in 1980to 8.5% in 2014) showed that 422 million diabetics live in 2016. Non-Insulin-Dependent diabetes (alsocalled Type 2 Diabetes) when not well managed could incite various complications including thedevelopment of diabetic retinopathy, diabetic nephropathy, diabetic nephropathy, and heart failureamong the many others. The ailment of diabetes is known to accompany the patient till this demise andthere is a high probability of its worsening if not treated at the exact time. Diabetes as such is a chronicdisease, its therapeutic regimen consists of multiple medications intended to treat the ailment as well itspossible complications and its comorbidities. 4 The Pharmaceutical MetamorphosisThe term pharmaceutical care was coined by Hepler in 1985 during his speech at the Hilton HeadConference, where he brought forth the covenantal relationship of pharmacists similar to that of amedical or nursing care and with an argument that increased responsibilities of pharmacists can furtherenhance the prescribed therapy. Over the last years, there has been an increasing number of pieces ofevidence which have shown enhanced patient outcomes with the indulgence of pharmacistsparticipation in the cooperative management of drug therapy. It has metamorphosised for the bettermanaging of chronic pathologies such as hypertension, diabetes, dyslipidemias, asthma, coronarydiseases, etc. 5 Multiple drug therapy given for the treatment of diabetes can incur drug-related problems(DRPs), readmissions and other such pharmaceutical care issues which can be perfectly governed andsolved by the pharmaceutical interventions. 4Health care for T2DM patientsThe management of T2DM calls for mutual participation of both the patient and health careprofessionals. The role of health care professionals greatly aids in assisting the patients' self-management of the ailment. The management of these chronic disorders include the initial diagnosiswith a detailed assessment and a workup of futuristic diabetes complications. The management isincomplete without a list of risk factors for complications prepared patient individually. Pharmaceuticalcare creates a professional relationship through which the services of both the pharmacist and thedoctor are combined, thus providing an augmented benefit than when deployed separately. Thismultidisciplinary collaboration enhances the optimal treatment corresponding to the patient’s healthstatus. 6 Table 1. Processes involved in the care of patients with T2DM 6 Stage Activity ComponentInitialassessment Historytaking • Specific symptoms of glycosuria/hyperglycemic• Predisposition to diabetes, eg, age, family history, obesity,lifestyle issues (eg, smoking,• diet, alcohol, physical activity, occupation)• Risk factors for complications: personal or family history ofcardiovascular disease,• overweight/obesity, smoking, hypertension, dyslipidemia• Symptoms of complications, eg, cardiovascular symptoms,neurological symptoms, renal• problems, foot and eye problems• Other medical conditions• Medications (if any)• Education (if any)• Psychosocial status, eg, attitudes about illness, expectations,resources – financial, social,• and emotionalPhysicalexaminations • Weight/waist: BMI, waist circumference• Cardiovascular system, eg, blood pressure measurement• Eyes, eg, pupil dilation• Feet, eg, skin condition, sensation• Peripheral nerves, eg, sensation• Urinalysis, eg, albuminLaboratoryevaluation • Glycemia: HbA1c, BGL• Lipids: LDL-C, HDL-C, total cholesterol, triglycerides• Renal function: plasma creatinine (eGFR), albuminuria• Other tests when necessaryTreatment plan Individualized treatmenttargets • Glycemic control: BGL, HbA1c• Control of risk factors for complications: lipids, blood pressure,BMI, cigarette consumption• Urinary albumin excretion• Physical activityDevelopment oftreatmentplans • Antidiabetic medications• Diet• Physical activity• Prevention/treatment of complicationsPatienteducation • Diabetes disease process• Treatment targets• Treatment plan• Antidiabetic medicines: dosing instructions, use of insulindevices, storage• requirements, special precautions, and common/importantadverse effects• Exercise• Diet• Prevention/treatment of complications, eg, foot care, smokingcessation, medications• for high lipid/blood pressure levels• Monitoring• SMBG (using glucose meter and interpreting the results)• Need for regular medical monitoringTreatmentadministration Medicationsprepared • Dispensed per legal requirements Appropriateinstructionsprovided • Prescription labels on directions for use• Ancillary labels (if required)Monitoring Monitorcompliancewithtreatmentplans • Medications• Exercise plan• Diet plan• Prevention/treatment plans for chronic complications• Scheduled medical monitoringMonitortreatmentoutcomes • Glycemic control: HbA1c, BGL, SMBG• Control of risk factors for complications: lipids, blood pressure,BMI, cigarette consumption• Presence of complications: cardiovascular system, peripheralnerves, renal, eyes, feetReview Monitoradverseeffects • Presence of adverse drug effectsReview of atreatmentplan basedonmonitoringresults • Consider treatment plan adjustment• Consider education adjustment• ReferralBGL, blood glucose level; BMI, body mass index; eGFR, estimated glomerular filtration rate; HbA1c,glycosylated haemoglobin; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-densitylipoprotein cholesterol; SMBG, self-monitoring of blood glucose; T2DM, type 2 diabetes mellitus. Table 2 Components of pharmacist interventions evaluated in T2DMStage Intervention ComponentTreatment plan/review Medication review • Medication review• Interventions based on patient outcomes(pharmacotherapy follow up)Patienteducation Patient education/consultation • Disease process• Goal setting• Lifestyle: physical activity, diet• Medication• Psychosocial support: patient health beliefs• SMBG: blood glucose meters• Prevention/treatment of complications: foot care,smoking cessation, hypertension, dyslipidemia• Unspecified/customized content(ie, education program tailored to patient’s priorknowledge)• Patient self-management servicesMonitoring Monitoring treatmentoutcomes • Review of blood glucose results• Physical examination (blood pressure, weight, feet,skin)• HbA1c measurementMonitoringcompliance • Adherence questionnaireOther Partnership with otherhealth professionals • Liaison with the prescribing doctor• Referral for patient education• Referral to a specialist nurse• Referral for medical adviceHbA1c, glycosylated haemoglobin; SMBG, self-monitoring of blood glucose; T2DM, type 2 diabetesmellitus Evidence of improved QOL through pharmacist interventions Mubashra Butt helmed a 6 month randomised controlled study in Malaysia which went on to prove theimproved QOL and medication adherence of T2 diabetics with pharmaceutical intervention. Of the 73poorly controlled diabetes mellitus type 2 (HbA1c P8%) patients 37 and 36 of them were randomizedto intervention and control group respectively. The patients in the intervention group receivedcounselling about diabetes, its complications, diabetes medication, lifestyle modifications along withtips for self-monitoring of the disease during their first, second and third visits at every during the first,third and 6 th month of the study. Additionally, assessments on the knowledge of the patients aboutdiabetes and its complication were performed and educational intervention was provided to those wholacked the same. At the end of the study, 18.2% of the patients in the intervention group achieved therequired HbA1C status. Significant improvement was seen in the intervention group (p= 0.03) than theother group. Also, there is a reported significant reduction in the percentage of patients with pooradherence (p = 0.02). Of the total five dimensions in EQ-5D-3L, the profiles of mobility and anxiety((p= 0.03) and (p< 0.0001) respectively) depicted significant changes within the intervention group.This study concluded with the necessary incorporation of pharmacist-led intervention in the treatmentof diabetes mellitus management programme for the better improvement in glycaemic control,medication adherence and quality of life among diabetics. 7 Table 2. Achievement of ADA target of glycaemic controlOutcome Control group Intervention group