Pharmacists Can Spur Switch to Recommended Drugs for Diabetes Patients With CVD

ANAHEIM, Calif. — A pharmacist-led intervention using notes in the electronic health record (EHR) proved effective for convincing primary care providers to switch veterans with diabetes and cardiovascular disease (CVD) to guideline-recommended care, a single-center VA-study showed.

A total of 180 recommendations were made by pharmacists in the EHRs of 102 patients. Of those, 23 recommendations were accepted by the primary care providers and four were rejected, for an 85% acceptance rate, reported Julia Bommarito, PharmD, of the Memphis VA Medical Center in Tennessee.

The accepted recommendations were associated with a 1% decrease in patients’ HbA1C during follow-up, according to findings presented at the American Society of Health-System Pharmacists midyear meeting.

Half of the recommendations involved switching patients from sulfonylureas to a GLP-1 receptor agonist or an SGLT-2 inhibitor, such as semaglutide (Ozempic) or empagliflozin (Jardiance). GLP-1 agonists and SGLT-2 inhibitors are guideline-recommended therapies for patients with diabetes and CVD, but veterans continue to be prescribed sulfonylureas, inexpensive drugs that are effective in lowering HbA1C but carry risks for hypoglycemia.

“We have a ton of patients in the VA system that are on sulfonylureas, and we know that’s not the best agent to prescribe,” Bommarito said. “It doesn’t have that CV benefit the way that empagliflozin and semaglutide have.”

The goal is to get patients on therapies that can “help them out in a bunch of different areas, not just A1c,” she told MedPage Today.

The study is ongoing, and the researchers plan to continue to track the rates of recommendation acceptance and biometric data, including systolic blood pressure (BP) and LDL cholesterol, as more appointments are completed and primary care providers have an opportunity to accept the recommendation.

The single-center cohort study used EHRs to retrospectively identify veterans with diabetes and CVD and a sulfonylurea prescription. Prospective recommendations with additions or modifications of guideline-directed medical therapy were then made to primary care providers via notes in the EHR.

Nearly all (96%) of the patients were male, 51% were Black, and the mean age was 68 years. About a quarter used tobacco, 89% had hypertension, 84% hyperlipidemia, and 24% had coronary artery disease. Patients with active outpatient prescriptions for insulin were excluded. Pharmacists wrote and submitted recommendations through the VA EHR system (CPRS) and primary care providers could co-sign or reject the recommendation, and begin making the changes if accepted.

The most common of the 180 recommendations made following the chart review were a switch to GLP-1 agonists or SGLT-2 inhibitors (50%), followed by hyperlipidemia interventions (23%), hypertension interventions (15%), and recommendations for tobacco cessation (12%).

Among the 23 patients whose providers accepted pharmacist recommendations, HbA1c levels decreased from a baseline mean of 7.7% to 6.7% at follow-up (P=0.005).

Monica White, PharmD, of the Columbia VA Health Care System in South Carolina, told MedPage Today that the study patients’ HbA1c levels seemed a little lower at baseline than might be expected. “It seems like a fairly healthy population for the veterans,” she said, but noted that the sample size was still fairly small.

White, who was not involved in the study, also said she was curious about how ongoing GLP-1 shortages might affect providers’ decisions to accept pharmacist recommendations. Bommarito acknowledged that prescriptions for GLP-1 agonists may require prior authorization, and patients may need to start on an SGLT2-inhibitor first when possible.

Bommarito’s team started sending notes through the EHR in August 2022 and 93 patients had been reviewed as of November 2023.

“The disappointing part is how we have not gotten that many responses from the primary care providers yet,” Bommarito said. “And that could be for a plethora of reasons — they’re very busy, very overworked.” Also, they may only see a patient once a year, she said.

A study limitation was the infrequent patient visits, which could slow the acceptance of pharmacist recommendations.

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