RxPharmacist

RxPharmacist

What Pharmacists Need to know about Diabetes

As per the Centers for Disease Control and Prevention (CDC), 34.2 million people, or 1 in every 10, in the United States have diabetes. Diabetes is 7th on the list of leading causes of death while the total estimated medical costs and costs associated with lost work and wages equates to an estimated $327 billion.

Diabetes, otherwise known as increased sugar levels (hyperglycemia) may be a result of decreased insulin secretion, decreased insulin sensitivity, or both. It can present itself in one of two forms of the following:

  • Type 1
    • Autoimmune destruction of beta cells
    • Loss of insulin production
    • Must use insulin injections
  • Type 2
    • Insulin resistance
    • Decreased insulin production over time
    • Associated with obesity, physical inactivity, family history
  • Signs and symptoms of diabetes include:
Signs and Symptoms of Diabetes
  • Risk factors:
Risk Factors for Diabetes
  • General Screening Criteria:
    • All patients with BMI greater than or equal to 25 kg/m2 + 1 risk factor
    • Children/adolescents with obesity + 1 risk factor
    • 45 years old if no risk factors are present
    • Pregnant women at 24-48 weeks
PrediabetesDiabetes
->Fasting plasma glucose (FPG) 100-125 mg/dL; or
->2-hour glucose after glucose tolerance test 140-199 mg/dL; or
->A1c 5.7-6.4%  
->Symptoms + random plasma glucose > 200 mg/dL; or
->2-hour glucose after glucose tolerance test > 200 mg/dL; or
->FPG > 126 mg/dL; or
->A1c > 6.5%  
  • Glycemic targets (per ADA guidelines):
    • A1c < 7%
    • 80-130 mg/dL pre-prandial plasma glucose
    • < 180 mg/dL post-prandial plasma glucose
    • A1c should be measured quarterly if not at goal
      • Or twice yearly if at goal
      • (A1c – 2) x 30 = average blood glucose
  • Drugs that may increase blood glucose levels:
Drugs that may increase blood glucose levels
  • Non-drug treatment options:
    • Smoking cessation
    • Weight loss
      • 3500 kcal weekly reduction = 1 lb weight loss
      • Waist circumference < 35 inches for females and < 40 inches for males
    • Nutrition
      • Carbs from vegetables, fruits, grains, and dairy
      • Omega-3 fatty acids and fiber
      • Limit saturated fat, cholesterol, and sodium
      • 15 g = 1 serving of carbohydrates
    • Physical activity
      • 150 min/week, moderate intensity
      • No more than 2 consecutive days off
      • Resistance training at least 2x/week
Drug treatments (oral medications)
  • Additional notes on oral drug classes:
    • Biguanides
      • Take with food
      • Use of alcohol increases the risk of lactic acidosis
      • Discontinue before any imaging with iodinated contrast; resume after 48 hrs
    • Meglitinides
      • Take 1-30 minutes before meals
      • If skipping a meal, skip dose as well
    • Sulfonylureas
      • Take with breakfast
        • Exception: Glipizide IR 30 minutes before breakfast
      • Glyburide – avoid in elderly and patients with renal impairment
    • Thiazolidinediones
      • Take with meals
      • May take weeks to take effect
      • Additional warnings:
        • Bladder cancer (pioglitazone only)
        • Risk of macular edema
        • Fracture risk
        • Hepatic failure
        • Resumption of ovulation
    • SGLT-2 Inhibitors
      • Caution when taking with diuretics and NSAIDs (due to risk of hypotension and acute kidney injury)
      • Additional warnings:
        • Genital infections
        • Hypotension
        • Increased LDL
        • Renal insufficiency
        • Ketoacidosis
      • Monitor K+ with Canagliflozin
    • DPP-4 Inhibitors
      • Take in the morning
Drug treatments (injectable medications)

Additional notes on injectable drug classes:

  • GLP-1 Agonists:
    • Exenatide and lixisenatide are administered 60 minutes before a meal
    • All others given without regard to food
  • Amylin Analog
    • Used in treatment of both type I and II diabetes
    • Reduce mealtime insulin by 50%

  • Drug treatments (Insulin)
    • For all insulins:
      • Side effects: weight gain
      • Warnings; hypoglycemia, hypokalemia
      • Never use pens for more than one individual
      • Most are 100 units/mL concentration
      • High risk medications
    • Dosing strategies
      • Basal insulin
        • Long or intermediate acting
        • Mainly affect fasting blood glucose
      • Bolus insulin
        • Rapid or short acting
        • Two purposes:
          • Prandial (mealtime) & correction (acute elevation)
Drug treatments (Insulin medications)
  • Insulins that do not require a prescription:
    • Regular insulin, NPH, and the premixed 70/30 combination
  • Insulin dosing for Type I diabetes:
    • Rapid-acting and basal insulin preferred
    • If using NPH and regular insulin
      • 2/3 NPH, 1/3 regular
    • Initiating basal/bolus insulin:
      • Calculate total daily dose (TDD)
        • 0.6 units/kg/day using TBW
      • Step 2: Divide TDD
        • 50% basal
        • 50% bolus
      • Step 3: Divide the bolus among 3 meals
    • Based on the amount of carbohydrates in a meal, meal-time insulin can be adjusted using rule of 500 (rapid-acting insulin) or rule of 450 (regular insulin)
      • (500 or 450)/TDD = g of carbs covered by 1 unit of insulin
  • Correction factor/dose
    • Factor:
      • Determines how much blood sugar will drop for every 1 unit of insulin. Uses the rule of 1800 (rapid-acting insulin) or rule of 1500 (regular insulin)
        • (1800 or 1500)/TDD = correction factor for 1 unit of insulin
  • Dose:
    • Amount of insulin required to bring blood glucose back to normal: [(blood glucose now) – (target blood glucose)]/   correction factor = correction dose
  • General treatment algorithm for Type II Diabetes:
General treatment algorithm for Type II Diabetes
  • For A1c greater than or equal to 8.5%: Jump straight to dual treatment
  • A1C > 10%: Think insulin
  • Cardiovascular benefit:
    • GLP1 agonists: liraglutide, semaglutide, exenatide
    • SGLT2 inhibitors: empagliflozin, canagliflozin
  • Patient-specific factors
    • Drugs that minimize hypoglycemia:
      • DPP4 inhibitor, GLP1 agonist, SGLT2 or TZD
    • Drugs that promote weight loss:
      • GLP1 agonist or SGLT2 inhibitors
    • Drugs with cost concerns:
      • Sulfonylurea or TZD
  • Combinations to avoid:
    • DPP4 inhibitors + GLP1
    • Sulfonylureas + insulin
  • Insulin dosing for Type II diabetes:
    • Initiate basal insulin after patient fails to reach or maintain goal on multiple oral therapies
    • Starting dose: 0.1-0.2 units/kg/day or 10 units/day
    • Titrate by 10-15% or 2-4 units once or twice weekly until fasting blood glucose at goal
    • If patient reaches fasting blood glucose goal but their A1c is still above goal:
      • Consider the addition of rapid acting mealtime insulin or GLP-1 agonist
  • Insulin administration:
    • Abdomen is the injection site (avoid belly button)
    • May also inject in thighs, buttocks, arms
      • Be consistent with administrations
    • Prime before each dose
    • Rotate sites
  • Hypoglycemia is common with insulin products, thus important to be aware of what to look out for and how to treat it
    • Defined as a blood glucose < 70 mg/dl
    • Symptoms: sweating, pallor, irritable, hunger, lack of coordination, sleepy
      • Beta blockers mask most except hunger and sweating
    • Treatment
      • Consume 15-20 g of glucose/simple carbohydrates
      • Recheck glucose levels after 15 minutes
      • Repeat if needed
      • Eat a small meal/snack to prevent recurrence
    • Glucagon is used only if patient is unconscious
  • Diabetes in pregnancy
    • Gestational diabetes: during pregnancy
      • Risks
        • Macrosomia
        • Hypoglycemia at birth
        • Obesity and type 2 diabetes
      • Management
        • Lifestyle modifications
        • Insulin added if needed (preferred)
        • Metformin and glyburide used
      • Goals:
        • Fasting < 95 mg/dL
        • 1-hour post-meal less than or equal to 140
        • 1-hour post-meal less than or equal to 120

We hope this review helped refresh your clinical knowledge on diabetes. Next up, we will take a look at dyslipidemia.

Best of luck,

Sam Tamjidi

RxPharmacist Team

References:

  1. National Diabetes Statistics Report, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/data/statistics-report/index.html. Accessed October 26, 2020.
  2. Micromedex Solutions. Greenwood Village, CO: Truven Health Analytics. http://micromedex.com/. Accessed October 26, 2020.

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More than just a study guide…

When I graduated from pharmacy school just a few short months ago, I found myself in the same predicament that most other students find themselves in … what do I do now? I have my degree, I have a year’s worth of rotation experience, but I still have to pass my licensing exams and find a job. I applied to RxPharmacist and was given the opportunity to write the Maryland MPJE Guide. 

When I applied to be an intern for RxPharmacist, I knew that I would be writing a study guide, but I had no idea that I would receive so many other benefits. RxPharmacist thrives off of a spirit of mentorship and connection. I was able to get personalized career advice, resume and CV reviews, and the contact information of other pharmacists who could help me to achieve my goals. The individuals who I have had the pleasure to connect with during my internship truly do give back to the pharmacy profession by assisting new graduates in any way that they can. This experience has really inspired me to give back, as well, since I know what it’s like to be a struggling new pharmacy graduate with many questions, but not so many answers. 

Now that I am at the end of my official internship, I can say with confidence that this experience has provided me with invaluable skills for my future in pharmacy. I am proud to have produced an MPJE guide to help other Maryland graduates like myself to pass their exams on the first try. Furthermore, it has been amazing to have one-on-one career guidance, constructive feedback, and pharmacy advice in a safe space with a trusted pharmacist. I am extremely grateful to have been selected to continue RxPharmacist’s mission of giving back to the profession.

Best of luck to all the new pharmacy graduates!

Lauren A., Pharm.D., 2019 RxPharmacist Intern

Shenandoah University, Class of 2019

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Intern Spotlight: The Value of a Good Internship

The idea of an internship is awesome. You basically get a trial run of anything you might want to try. You get the opportunity to meet people in a field and learn all about an industry that interests you.

But it does come at a cost- your time.

Your time is the most valuable thing you own; especially when you only have a few years of school and free summers before you need to make a career choice. Therefore, when picking an internship, it’s important to look for someone who values your time for what it’s worth; which is a hard concept to define. However, after working for a start-up like RxPharmacist, I began to see specifically what it looks like. See, a start-up, or any other small business, understands the  value in time because the truth is, time is more than just money for them. The time it takes to learn a new program determines whether or not it is worth the money. The time it takes to finish creating a product determines how many people you are willing to hire. A start-up constantly needs to prioritize things to ensure the best use of their time. Which is kind of like what a student does. You have unique qualities and traits that you want to market to everyone else, and you are paving a unique pathway to your future career. And what makes you unique? Your experiences; or in other words, how you spend your time.

With RxPharmacist, I was never stuck working in one area. I had the opportunity to learn and gain experience with website development, search engine optimization, competitive pricing, employee recruitment, and advertising. I worked directly with the CEO of a company and got a front row seat to the mechanics of how a business is managed and built from the ground up. I saw how a business plan was written and entered the vast world of business competitions- which are quite exciting. I learned the value of networking and building connections. I learned that the field of pharmacy is so much bigger than I had ever imagined and that your opportunities are only limited by your ambitions.

To top it off, I was able to work from home and created my own schedule so that I never had to waste any time with commuting! 

This internship has opened my eyes to so many opportunities; however, above all, I value this experience in particular because I learned what it means for someone to value my time. I was constantly encouraged with my school work and with applying for future internships. I was asked what interested me and what I wanted to learn about. I was given advice about the field of pharmacy and about working in general. Just recently, I mentioned I was considering getting a second degree and was immediately connected with someone who is currently working on that degree. The mentorship that I gained from this experience was invaluable, and I would encourage any student to seek out an opportunity such as this one. I can assure you, it is well worth your time.

Sincerely,

Madeline Wright

University of Florida College of Pharmacy

PharmD Candidate c/o 2022

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How does RxPharmacist Create Study Guides?

You are probably wondering how does RxPharmacist create our study guides? It’s not easy. We dedicate at least 6-9 months to create just 1 of our study guides! This time period is spent on content creation, editing, calling up Board of Pharmacies for each respective state, and ensuring a high quality and up-to-date guide.

Each guide is created by a pharmacy graduate who recently passed their MPJE licensure exam the first time for that respective state or a seasoned pharmacist who recently passed their MPJE licensure exam the first time due to moving and finding another job in the other respective state. We dedicate more time with our pharmacy graduates as they are paired up with pharmacist preceptors that review their work week by week, with a careful eye on attention to detail, accuracy, and outside of the box questions that may show up on the exam. For the pharmacist, we also pair them with a fellow pharmacist that serves as a second pair of eyes in reviewing the content creation for accuracy and attention to details.

After this process, we also get our guides vetted through mostly pharmacy students to serve as our Beta test group to provide feedback and further assist us in creating our study guides.

The reason we focus on pharmacy graduates and pharmacists is to give back in supporting our pharmacy profession. The pharmacy graduates get paid to study which they need to do anyways to pass their board exam and may need financial help during their transition from pharmacy graduate to pharmacist. We support all of our pharmacy graduates with helping them access our network, reviewing their resume, testing their interviewing skills, and more to ensure they are successful in the workforce.

For the seasoned pharmacist, the same applies. They may have a life situation and need to move to another state and find another pharmacist job in that state. We support our pharmacists by giving them the opportunity to write a study guide to support them financially while connecting them with others in our network so they make an easy transition as they move to their new state of practice. We also provide resume, interviewing skills, and connections so they may also be successful in their careers.

As you can imagine the process is tedious and is meant to be symbiotic with always creating a win-win-win. The pharmacy graduate/pharmacist wins in financial support and job assistance, RxPharmacist wins in getting a new study guide to market to further support more students and pharmacists, and you win in getting a high quality guide. The end product is an affordable, high-quality, and up-to-date pharmacy test-prep study guides so you can pass the first time!

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The Creation of RxPharmacist

Getting through pharmacy school is not easy. Second year was the worst and finally when you get to your fourth year you need to focus on getting a residency or fellowship program. The obstacles don’t stop there, you then need to finally graduate and take your licensure board examinations, mainly the NAPLEX and state specific MPJE exam. Those few months in between graduating and starting your residency, fellowship, or first job out of school are tough transition periods for pharmacy graduates as they need to pass their boards in order to start their first paid income job.

I’ll tell you how RxPharmacist got created. One of my pharmacy school classmates, Mike, received an offer and moved his family of three little boys from Florida to Tennessee contingent upon him passing his board exams. He called me sobbing at 2am in the morning, I could hear the desperation in his voice. Knowing Mike for the past 4-years during pharmacy school, I never saw him this low and said I will do everything in my power to help him. That same morning, I started creating study guides and working with my fellow classmates. After using them, he passed and said how this will help so many people who are struggling. That is how RxPharmacist got created out of a call of service that helps pharmacy graduates and pharmacists nationally as being one of the only companies to offer this service and helping over a thousand students pass their board licensure exams the first time. 

A key signature among all of our services and products are serving and giving back to our pharmacy profession. We offer a unique, one-of-a-kind pharmacy graduate transition program to assist students during that time period between graduation and starting their first job and connecting them to preceptors and mentors to ensure they are successful in this saturated pharmacy market. Check out our internship page for more information. We create a symbiotic relationship with students ensuring everything we do, we put them first. Even with our customers, we ensure to reach out and follow up with them as we enjoy seeing the success of our students, and we take down our guides if they need to be updated even though we lose potential funds to help sponsor future pharmacy graduates. Think about this. Many companies don’t do this, they just reuse their content over and over, without updating or tweaking. We understand why, it’s extremely time consuming but someone has to do the right, good work that needs to be done.

We hope to continue RxPharmacist to continue to serve our pharmacy profession and disrupt the test-prep industry in creating affordable, high quality, and up to date guides.

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