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Management of Type 2 Diabetes
Sorting Through the Confusion and
Current Clinical Recommendations for Management
An Overview for Pharmacists and Pharmacy Technicians
Mary Jo Carden, RPh, JD
Principal, Carden Associates
Marsha K. Millonig, MBA, RPh
President/CEO
Catalyst Enterprises, LLC
E.L.F. Publications, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmaceutical education. This program has been approved for 1.5 contact hour (0.15 CEU). Universal Program Numbers: 406-000-08-003-H01P & 406-000-08-003-H01T The expiration date for this program is 1/31/10. Learning Objectives:
Pharmacists:
After completing this lesson, pharmacists should be able to:
 Provide an overview of current dietary guidelines for individuals with type 2 diabetes .  Describe recently approved brand and generic medication therapies for type 2 diabetes .  Understand current treatment protocols for the management of individuals with type 2 diabetes .  Discuss recent warnings and risks when taking certain medications and the impact on treatment.  Describe resources for current information on type 2 diabetes .  Explain important patient counseling for patients with type 2 diabetes .
Pharmacy Technicians:
After completing this lesson, pharmacy technicians should be able to:
 Understand the importance of diet and exercise for individuals with type 2 diabetes .  Describe recently approved brand and generic medication therapies for type 2 diabetes .  Understand current treatment protocols for the management of individuals with type 2 diabetes .  Know about recent warnings and risks associated with certain medicines and their impact on treatment.  Describe resources for current information on type 2 diabetes . The incidence of type 2 diabetes continues to increase in recommendations for prevention and treatment of Type 2 the United States. New therapies and approaches are constantly being considered to manage this disease state. Pharmacists are an integral health care professional to assist II. Etiology and overview of type 2 diabetes
patients in managing type 2 diabetes. Developments in the Type 2 diabetes occurs when an individual’s pancreas treatment and management of type 2 diabetes can be ceases to produce insulin sufficient to properly control glucose overwhelming for any pharmacist and warnings and issues levels in the body. Individuals diagnosed with type 2 diabetes related to certain medication therapy can create confusion for usually are overweight at the time of diagnosis, although pharmacists and their patients. This program will provide individuals who are not overweight, particularly older adults pharmacists an overview of the current dietary and medication are also diagnosed with type 2 diabetes. At the time of therapy guidelines for the treatment and management of type 2 diagnosis, most individuals show signs of insulin resistance. diabetes. This program will specifically consider newly Insulin resistance occurs because organs and muscles do not available brand and generic therapies and the impact of recent properly receive the insulin produced by the pancreas and then warnings for certain medications on treatment protocols. a negative feedback loop produces greater amounts of insulin in an effort to force cells to accept insulin. The cells of I. Introduction
individuals with type 2 diabetes do not properly convert Diabetes affects an estimated 194 million adults glucose to energy because of the lack of insulin and therefore, worldwide and more than 20 million individuals in the United these individuals have a state of hyperglycemia, or abnormally States. Approximately 90% to 95% of affected individuals high levels of blood glucose levels. The process of developing have type 2 diabetes. Type 2 diabetes is a condition where the type 2 diabetes is gradual and individuals are often not body does not produce enough insulin and/or the cells in the diagnosed until symptoms commonly associated with the body do not respond normally to insulin. Diabetes is the sixth leading cause of death by disease in the United States, and costs approximately $132 billion per year in direct and indirect medical expenses. Type 2 diabetes usually occurs in adults  being overweight because fat interferes with the over the age of 40, but is becoming increasingly common in  race, African Americans, Hispanic Americans, In 2002, nearly 250,000 people died of diabetes. Diabetes Asian Americans and Native Americans are more also leads to other serious, expensive complications and disabilities such as stroke, heart disease, kidney disease, blindness, and amputations of legs, arms, and other  a diagnosis of prediabetes, characterized by elevated blood sugar that does not rise to the level The incidence of type 2 diabetes has lead to massive public health initiatives to help prevent occurrence and to properly diagnose and manage those with diabetes and those  family history and other genetic factors; who are at high risk for diagnosis. The prevalence of type 2 diabetes has also created a lucrative and growing market for  HDL levels less than 35 mg/dL or triglycerides of pharmaceutical interventions used to manage the condition and prevent further complications. Pharmacists and the pharmacy technicians that assist them in providing patient care A diagnosis of type 2 diabetes usually occurs when an play an important role in assisting patients in preventing individual presents with one or more of the following signs diabetes and in ensuring proper diagnosis and medication management for diabetes and the underlying conditions that  increased thirst caused by cell dehydration that occurs because the sugar in the bloodstream pulls Much of the existing information regarding current prevention and treatment guidelines for type 2 diabetes may be  constant state of hunger even after eating because confusing to pharmacists and pharmacy technicians alike. cells are deprived of energy in the form of sugar; New studies often update the existing recommendations  constant fatigue because lack of energy from sugar; understood by pharmacists and pharmacy technicians. In the  blurred vision caused by fluid from the cells in the past 2 years, the Food and Drug Administration (FDA) has lens of eyes causing the inability to focus; approved several new medications for the condition, some  delayed healing of sores or infections; women with novel mechanisms of action; new generics are anticipated often experience an increased number of vaginal in 2008 and beyond; and some newer, existing medications have been under scrutiny based upon clinical and consumer research that exposes dangers and high costs associated with  a condition called acanthosis nigricans, dark, these products. Sorting out all this information can be difficult velvety patches of skin in the creases and folds of for pharmacists and technicians. This article provides an the body, particularly the neck and armpits; usually overview for pharmacists and pharmacy technicians to gain a better understanding of the current guidelines and In the United States, nearly 41 million Americans age 40- individuals receive appropriate education and training for self 74 years have prediabetes and are at risk for developing management, maintain a healthy weight, and treat and prevent stroke, heart disease, and eventually a diagnosis of type 2 conditions commonly associated with type 2 diabetes , diabetes. Often, individuals with prediabetes have no signs or including hyperlipidemia, and hypertension. symptoms associated with diabetes, which is why it is critical for individuals with risk factors for developing type 2 diabetes Generally accepted parameters for type 2 diabetes to be carefully monitored and encouraged by pharmacists and management include a hemoglobin A1c level of 7% or less; other health care professionals to exercise, not smoke, pre-prandial blood glucose levels of 90-130 mg/dL; and peak maintain a healthy weight, and have an overall healthy diet. postprandial levels of 180 mg/dL or less. Certain individuals such as older individuals, patients with other complex medical III. Clinical considerations for type 2 diabetes and
conditions, psychiatric conditions, or adverse social conditions prediabetes diagnosis
might have different goals with less stringent glycemic The preferred diagnostic method is to measure fasting control. Other factors that must be considered in treatment blood glucose levels in the morning. A diagnosis of type 2 include the reduction of cardiovascular risk factors and the diabetes is determined by any one of the following levels:  fasting blood glucose levels (8 hours of fasting ) of Most type 2 diabetics receive therapy with oral anyti- hyperglycemic agents, but insulin will likely be required as  the oral glucose tolerance test: blood glucose levels later treatment when oral therapies are no longer effective. of 200 mg/dL or more 2 hours after drinking a Recently, the FDA approved a new injectable treatment in a beverage with water dissolved in 75 mg of glucose. new class of medications called incretins. If this class of  random blood glucose levels of 200 mg/dL taken at medications proves successful, then more individuals with any time along with the presence of diabetic type 2 diabetes might be adding non-insulin injectable therapy Two tests exist to determine the presence of prediabetes Most people with type 2 diabetes are currently managed conditions: impaired fasting glucose and impaired glucose with a combination of medications from different classes. tolerance. Individuals tested using the impaired fasting Some of these medications are individual agents while some glucose test have levels of 100-125 mg/dL after an overnight 8 are available in combination form. This article focuses hour fast and individuals tested using the impaired glucose primarily on new pharmacological treatment for type 2 tolerance test have levels of 140-199 mg/dL 2 hours after an diabetes beginning with newer treatments, except Glucophage® (metformin hydrochloride, Bristol-Myers Squibb Company) that is described first because it is often Pharmacists and pharmacy technicians must be aware that used in combination with other products and is considered a many individuals with both diabetes and prediabetic standard treatment. A brief overview of some surprising conditions are often not diagnosed. As the first line of access findings regarding the potential impact of tight glucose control to many individuals in the community, pharmacists should be and experimental treatments follows in section V below. aware of individuals who might be at risk for diabetes and make recommendations for testing. Metformin

Metformin is commonly used in the treatment of type 2 IV. Current medication treatment options for type 2
diabetes alone or in combination because it is considered by diabetes
experts to be a well-researched and generally well-tolerated The year 2007 proved to be an interesting one in the agent. It is generically available so it is also very cost effective treatment of type 2 diabetes . In 2006 and 2007, new for patients. A 2003 studies called the Diabetes Prevention medications with unique mechanisms of action were approved Program found that in addition to diet and exercise, metformin and some medications in a relatively new class of medications, can also prevent the onset of diabetes in a pre-diabetic patient. known as the thiazolidinediones (TZDs), were controversial Furthermore, use of this agent is promoted in the government because studies suggested that use of these products might sponsored comparative effectiveness study. exacerbate heart failure and other cardiac conditions in certain individuals. Furthermore, a government-commissioned Metformin, in the class of medications known as comparison study examined the effectiveness and costs of biguanides, works to reduce glucose production in the body existing medications for type 2 diabetes and made and also postprandial levels. Its unique mechanism of action recommendations regarding medications considered most decreases hepatic production of insulin, decreases intestinal effective for treatment. This article reviews existing absorption of glucose, and improves insulin sensitivity by management recommendations and classes of treatment for increasing glucose uptake and utilization. Insulin secretion is type 2 diabetes and specifically examines the new classes of stabilized while fasting and daylong levels actually decrease. medications, the warnings for TZDs, and the Unlike other older, generically available oral agents, such as recommendations provided by the comparative effectiveness the class known as the sulfonylureas, metformin does not cause hypoglycemia or hyperinsulinemia except if used with other agents that result in this side effect. Overview of treatment options for type 2 diabetes

Metformin works well in patients who are obese because pharmacological treatment for type 2 diabetes are to stabilize it has been associated with visceral fat reduction. The presence fasting and long-term blood glucose levels, ensure that of visceral fat often contributes to insulin resistance. It also has been shown to be extremely effective against and GIP rapidly stimulate the release of blood insulin only cardiovascular morbidity and mortality that often occurs in when blood glucose is increased which then increases the individuals with type 2 diabetes, especially in comparison to capacity of the pancreas to release insulin only after eating. sulfonylureas and insulin with similar long-term measures of When increased levels of glucose are present in the body, H1Ac. This is one of the reasons that metformin is GLP-1 signals alpha cells to suppress glucagon release. recommended by consumer groups as a safe and effective Incretins have also been shown to have a positive effect on product in comparative effectiveness studies, particularly preservation of beta islet cells in the pancreas. considering recent concerns with cardiovascular disease associated with the TZDs. Research has found that in people with diabetes, levels of GLP-1 are diminished, the insulinotropic response to GIP is A 2004 study found that metformin has also been shown diminished but not absent, and these two factors result in loss to be effective in improving lipid profiles. This study found of glycemic control. Current research and therapy goals are to this effect is generally limited to metformin, the TZDs, and enhance the presence of incretin by suppressing rapid uptake, alpha-glucosidase inhibitors. Again, this considered another mimicking the impact of the incretins in the body. positive benefit of the use of metformin. Two medications that impact the incretin system have The dosage of metformin varies with each individual been approved within the past two years: Januvia™ according to tolerance and glucose control. Maximum daily (sitagliptin, Merck & Company), an oral medication that dosages in most adults should not exceed 2,550 mg. reduces the uptake of naturally occurring incretins; and Byetta Individuals should be dosed at the lowest dose possible with (exenatide injection, Eli Lilly & Company), an injectable gradual dose increases, generally 500 mg twice daily with medication that mimics the production of incretins. Other meals or 850 mg daily. If dosage increases are necessary, it should begin with 500 mg increases daily at weekly intervals or one 850 mg tablet daily at every other week intervals. When using extended release tablets, administration is The FDA approved Januvia for the treatment of type 2 diabetes in 2007. Januvia acts as a dipeptidyl peptidase-4 (DPP-4) inhibitor that blocks a receptor site that causes the The most severe reaction from the use of metformin is the rapid uptake of incretins after release. The goal is to ensure risk of lactic acidosis, a very rare but serious side effect that higher levels of endogenous incretin levels. has generally been known only to occur in individuals with risk factors. Patients with the following risk factors should not Januvia is an orally administered medication with a be prescribed metformin: individuals with elevated creatinine recommended dosage of 100 mg once daily for individuals levels of (Cr >/= 1.5 mg/mL in males or >/= 1.4 mg/mL in with type 2 diabetes. Januvia has been administered females), congestive heart failure, metabolic acidosis, and concomitantly with oral sulfonylureas, metformin, and TZDs hypoxia. Individuals who are age 80 and over should not be but should not be administered with insulin. Januvia alone and given metformin unless creatinine clearance is normal. in combination with other products has been shown to reduce Another common side effect associated with metformin is overall HA1c levels compared to placebo without weight gain. vitamin B12 deficiency, which is known to occur in 10%-30% Dosages should be decreased as follows for individuals of individuals taking the medication and occurs more with impaired or end-stage renal disease: 50 mg once daily for commonly in individuals prescribed the medication for 10-15 individuals with CrCl ≥30 to <50 mL/min ~Serum Cr levels [mg/dL] men: >1.7– ≤3.0; women: >1.5– ≤2.5; 25 mg once Nearly 50% of patients who begin therapy with daily for individuals with CrCl <30 mL/min ~Serum Cr levels metformin will experience mild gastrointestinal conditions mg/dL] Men: >3.0; : >2.5. Prior to beginning therapy, that subside within the first couple of weeks of therapy and are patients’ kidney function should be monitored and monitoring reduced when taken with food. Side effects are more common should continue through duration of therapy. in dosage levels above 2,000 mg per day. The most serious reactions seen in post-marketing surveillance includes serious allergic and hypersensitivity New Agents Affecting the Incretin System

The newest frontier in the treatment of type 2 diabetes reactions associated with the skin, including Stevens- focus on the incretin system. Incretins are naturally occurring Johnson’s syndrome, angioedema, and other reactions. If any hormones found in the gastrointestinal tract that enhance of these reactions occur, treatment should be stopped glucose-dependent insulin release from the pancreas and help immediately, the condition should be evaluated and treated, to regulate overall glucose control in the body. While basal and alternative treatment for diabetes considered. Mild- level incretins occur in the body, levels increase upon the moderate gastrointestinal side effects, including nausea, introduction of food into the body through the gastrointestinal abdominal pain, and diarrhea, are the only other reported side tract in comparison to when glucose is administered effects. Instances of hypoglycemia occurred when used in intravenously. These findings suggested the benefits of the incretin system in controlling type 2 diabetes. Another DPP-4 inhibitor, Galvus (vildagliptin, Novartis), Two types of endogenous incretins have been identified has been submitted for review under a new drug application as important factors in regulating glucose levels in type 2 (NDA) with the FDA. Approval has been delayed primarily diabetics: glucagon-like peptide 1 (GLP-1) and glucose- because of issues related to serious skin conditions that dependent insulinotropic polypeptide (GIP). Release of GLP-1 occurred in tests with monkeys and FDA’s request for additional information regarding patients with kidney proliferator –activated receptor gamma (PPARγ), a receptor impairment. According to business industry sources, FDA that regulates the transcription of genes used in glucose and might make a determination in early 2008. lipid metabolism. These receptors are primarily present in fat tissue, but are also located on other insulin sensitive tissues. When PPARγ is stimulated, a greater number of insulin- Byetta is the first medication in its class that acts as an sensitive adiocytes are produced that results in greater glucose incretin mimetic. It is an injectable product that mimics the control but might also result in protection of pancreatic beta- effects of endogenous GLP-1. Byetta immediately improves beta-cell secretion of insulin during phases of elevated blood glucose. It also suppresses first phase insulin response, slows Rosiglitazone has also been specifically shown to gastric emptying, and reduces food intake and reduces body decrease the amount of free fatty acids (FFAs) and retain fat weight. These rapid responses result in improved HA1c levels where it belongs while reducing the potential for lipotoxicity and glycemic control. Byetta is approved for use in in the pancreas, liver, and other muscles. The mechanism of combination with other products including sulfonylureas, action is based on the suppression of tumor necrosis factor metformin, and TZDs with suboptimal glucose control. (TNF-α) through two means: increasing the insulin sensitivity of the cell and improving the anti-lipocytic effect of insulin In clinical studies, significant weight loss occurred in the and reducing levels of TNF-α that are known to decrease the Byetta group compared to those using placebo. Study groups dosed with higher levels of Byetta were found to have greater weight loss. Weight loss was not correlated directly with FDA approved Actos and Avandia for marketing in 1999 reductions in HA1c and even patients who did not experience and more than 1 million individuals take Avandia alone. Much weight loss experienced improvements in glycemic control. of the popularity associated with TZDs relates to the promising results associated with beta-cell preservation. In Byetta is available as a prefilled pen that contains 5 2006, total sales for both products was $2 billion. In early micrograms of active ingredient for all patients. Pharmacists 2007, the use of these products raised additional questions and technicians should understand the dosing regimen for because of study findings released posing potential safety Byetta and pharmacists should counsel patients on the concerns for individuals with certain heart conditions. The appropriate administration intervals. Byetta cannot be taken after a meal because its mechanism of action works with the incretin system that responds to introduction of food into the In May 2007, the New England Journal of Medicine published a meta-analysis of the impact of rosiglitazone on cardiac morbidity and mortality. The study examined a Dosage should begin with 5 micrograms twice daily 60 literature review, website review, and FDA findings on minutes (one hour) before the morning or evening meals and rosiglitazone. To be considered, studies were required to be then depending upon response, increased to 10 micrograms conducted over at least a 24-week period, include a control twice daily over a period of a month. The product is group of patients using rosiglitazone, and include findings of administered as a subcutaneous injection in the thigh, information related to cardiac morbidity and mortality. Of a abdomen, or upper arm. A demonstration video for the proper possible 116 available studies, 42 met the inclusion criteria. administration for Byetta is included on the product website, The meta-analysis found that based on the studies, the odds www.byetta.com. Pharmacists should review this video to ratio for a myocardial infarction (MI) in the rosiglitazone provide proper counseling and administration techniques and group was approximately 1.43 (p=0.03) and for death from also recommend that patients watch this video to reinforce cardiovascular causes was 1.64 (p=0.06). Participants had a mean age of 56 years old and average HA1c of 8.2% The TZDs, the Facts and Controversy
study concluded that the use of rosiglitazone is associated with The TZD class of medications includes Avandia® an increased risk of MI and death from cardiovascular (rosiglitazone maleate, GlaxoSmithKline) and Actos® incidence that is considered of borderline significance and (pioglitazone HCl, Takeda Pharmaceutical Company Ltd.). recommended that patients strongly consider these risks when These companies also market the TZDs as combination products with other generically available oral diabetic Upon release of these findings, FDA issued a safety alert medications: Avandamet® (rosiglitazone maleate/metformin on the issues associated with the use of rosiglitazone and also HCL); Avandaryl™ (rosiglitazone maleate/glimepiride), took additional action to consider issues associated with the which is a combination with a sulfonylurea; Actos PlusMet® potential negative cardiovascular outcomes associated with (pioglitazone HCl/metformin HCl); and, Duetact™ rosiglitazone. In August 2007, FDA added a black box warning to the professional labeling and required that a This class of medications are often dubbed “insulin patient-specific MedGuide be distributed warning of the sensitizers” because of their ability to reduce insulin resistance potential for worsening of cardiovascular failure when using and to allow cells to use insulin more efficiently. These drugs rosiglitazone (including combination products). Despite the also reduce the rate of insulin production by the liver. TZDs lack of specific findings associated with the use of primary advantage over other medications for type 2 diabetes pioglitazone and its combination products on worsening of heart failure or other cardiovascular incidence, warnings were also added to these products. Specifically, TZDs are agonists of peroxisome In September 2007, the Journal of the American Medical cardiovascular incidences as once suggested and could change Association published the findings of a second meta-analysis the way that type 2 diabetes is treated in the future. that examined the long-term impact of the use of rosiglitazone on cardiovascular health. The search included Medline, IV. New Research in the Treatment of Type 2 Diabetes
GlaxoSmithKline’s clinical trials register, FDA website, and and the Future of Management
other reviews and analyses. Studies included those that A. Is lowering glucose levels the answer to
randomized for rosiglitazone use with at least 12-months of reducing cardiovascular incidence among
follow-up care with monitoring for cardiovascular incidence type 2 diabetics?
with numerical data on adverse events. Four studies of 140 Researchers engaged in a study, Action to Control reviewed were included in the final analysis. This study also Cardiovascular Risk in Diabetes (ACCORD) with found that patients who use rosiglitazone for a period of 12 approximately 10,000 participants, funded by the National months or more are at significantly increased risk of MI Institutes of Health sought to examine the impact of lower (relative risk of 1.42; p=0.06) and heart failure (relative risk than recommended blood glucose levels on the incidence of 2.09; p<0.001) without a significant risk of cardiac mortality cardiovascular events in patients with type 2 diabetes. The researchers halted their efforts after 257 individuals in the treatment-intensive group died of cardiovascular As a result of these findings, in November 2007, FDA complications compared with 203 in the standard group. The upgraded the warnings released in August 2007 and treatment intensive group had HA1c levels of less than 6%, specifically added an additional black box warning associated the standard for individuals without a diagnosis of diabetes. with rosiglitazone. This warning indicates that when compared The findings did not point to a single class of medications as to placebo, rosiglitazone shows an increased risk of the the primary reason for the increased incidence of potential for myocardial ischemic events, including MI and cardiovascular death. Patients were given a combination of all angina. The strengthened warnings were not added to current class of diabetes medications available on the market: metformin;TZDs, primarily rosiglitazone; insulin; sulfonylureas; exenatide; and acarbose. In the wake of these findings, health care professionals might find it difficult to determine how to proceed in treating Researchers caution that more research is necessary to patients with type 2 diabetes. Pharmacists should never advise conclusively determine the link between the lowered HA1c patients to immediately discontinue treatment with any type 2 levels to cardiovascular death. In the meantime, patients diabetes product, but rather should consult with their physician should strive to maintain HA1c levels to the current to determine whether a change in therapy is necessary. recommended levels of about 7%. These findings will be Another retrospective study of elderly individuals with diabetes suggests that the risks of cardiovascular incidents associated with the use of TZDs might outweigh the benefits B. Other frontiers in the treatment and
of using these products, especially in the elderly and even management of type 2 diabetes
those without baseline cardiovascular risk. The findings also Clinical research in the field of type 2 diabetes today suggest that more research is necessary to determine whether focuses on prevention of the condition by examining the the cardiovascular risks are specific to rosiglitazone or impact of beta-cell preservation and other cellular level actually exhibit a class effect. Until this research is concluded, interventions, including medications and transplant, to health care professionals must make individualized preserve and protect the pancreas. Goals also include determinations to weigh the benefits and risks associated with identifying early cellular level risk factors and prevention of using TZDs. In the interim, some prescribers might choose to those risk factors. These goals are also paired with the goals of initiate or therapy with metformin alone or in combination, a identifying the reasons for certain concomitant conditions product that as suggested earlier is well researched, cost commonly associated with type 2 diabetes and seeking ways effective, and is considered to be safe. to prevent or cure these conditions. Today’s research combines traditional medications with new biotech Pharmacists play an important role in helping to identify innovations that allow researchers to learn more about the patients with diabetes who might be experiencing cause and treatment of type 2 diabetes at the cellular level. cardiovascular symptoms. Pharmacists should note sudden changes in patient weight and determine whether an individual is experiencing edema caused by a cardiovascular issue. Type 2 diabetes is a growing and costly problem in the Furthermore, pharmacists should communicate the risks to United States. Today, pharmacists can play a key role in patients and inform the patient of the risks that may be preventing the incidence by encouraging patients to engage in identified, including sudden weight gain, shortness of breath healthy behaviors. With face-to-face access to patients, pharmacists can help individuals develop a plan for a healthy life style and coach these individuals to achieve goals. The suspected risks associated with the use of TZDs and the high incidence of cardiovascular events among individuals Pharmacists also play a role in identifying patients who with type 2 diabetes has spawned much research into the are at risk or have developed type 2 diabetes. Pharmacists relationship between the use of medications and the incidence should communicate diabetic risks with patients and counsel of CVEs, as well as the impact of glycemic control. Tight them on the signs and symptoms. For patients who have glycemic control might not yield the reductions in developed diabetes and require medications, pharmacists can help play a role in providing the latest information about medication treatments and work with physicians to optimize therapy. Pharmacists should never suggest sudden discontinuation of any therapy and should not unnecessarily alarm patients as new research emerges. Rather, pharmacists ensure that their knowledge is current and correct and evaluate communications to patients based on this information. Pharmacists can also become certified diabetes educators through the American Association of Diabetes Educators to become part of an individual’s care plan with the goal of optimizing the overall treatment of type 2 diabetes. Pharmacists who opt for this role must meet minimum standards for experience with patient diabetes self-management and after certification must do continuing education specific to diabetes management. Pharmacists interested in becoming a certified diabetes educator or for additional resources on assisting patients with managing diabetes, visit http://www.diabeteseducator.org/. There are also numerous certification programs offered by national and state pharmacy associations that provide education to pharmacists who are interested in creating a diabetes medication therapy management and/or disease management program.

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