- December 17, 2015
When it comes to managing glucose levels in the hospital, the pharmacist can play an active role and, with broad expertise in medication management, make a unique contribution.
Pharmacists are well informed of the risks associated with hyperglycemia and the benefits of tighter glycemic control, as well as the impact of the all-too-common hyperglycemia to hypoglycemia swing.
If a patient is diagnosed with diabetes, pharmacists may already be involved in their care. If hyperglycemia or hypoglycemia results from the stress of an acute illness, a pharmacist may contribute a different and valuable perspective than the hospital clinical team. Findings about the benefits of glucose control in different hospitalized patient populations have been inconsistent. As a result, many hospitals form multi-disciplinary teams to evaluate research and set achievable glycemic targets. Pharmacists should be an integral part of these teams.
Pharmacists have detailed knowledge of the potential impact on glucose levels that may result from certain drugs used to treat a primary illness. If these drugs affect glucose metabolism, the patient’s levels should be monitored and addressed.
Pharmacists are also knowledgeable about whether tight glycemic control is important to ensure the effectiveness of a particular medication. Certain illnesses and drug therapies may merit more vigilance of glucose levels to enhance treatment.
Further, patients whose hyperglycemia is treated with medications other than insulin will benefit from the participation of a pharmacist on the clinical team. Glucocorticoid drugs are often used to treat diseases caused by an overactive immune system, such as allergies, asthma, and autoimmune diseases. These medications can exacerbate underlying hyperglycemia and dosage will benefit from evaluation by a pharmacist to counter this problem.
Some patients with known diabetes will enter the hospital on oral hyperglycemic medications that may be contraindicated during the course of their hospitalization. For example, sulfonylureas exert long lasting blood sugar control. In hospitalized patients with unpredictable food intake and meal timing, they may increase the risk of hypoglycemia.
Metformin is another common diabetes medication with increased risk for seriously ill patients who may develop renal insufficiency or an unstable hemodynamic state. Combining this medication with radiocontrast agents for imaging exams can also cause renal problems. Additionally, treatment of diabetes with thiazolidinediones may result in salt or water retention and is contraindicated for patients suffering from edema as well as advanced heart failure.
On the other end of the treatment, pharmacists can contribute to plans for transitioning patients from intravenous to subcutaneous insulin as patients prepare for the transition to an outpatient setting. Use of oral hypoglycemic therapies may resume once a patient leaves the hospital. Therefore, as members of the glycemic management team, pharmacists should work closely with inpatient diabetes educators or nurses to help patients clearly understand their ongoing diabetes treatment plan.