A: Inform MD that most insurance plans have strict guidelines regarding the use of a CGM in place of conventional blood glucose testing. CGM products have been shown to be beneficial in reducing A1C levels and hypoglycemia events. CGM products allow patients to monitor their blood sugar day and night and alert them to hyperglycemia or hypoglycemia. Glucometers should be selected based on several factors, such as ease of cost and insurance coverage, flexibility, information retrieval and, of course, usage. Some CGM products also connect to insulin pumps, but since this is not a factor for MD, she can consider any product.1 CGM products in the United States include the Dexcom G6, Abbott’s FreeStyle Libre system, and Medtronic’s Guardian Sensor 3. Since MD only uses insulin at bedtime, most insurance companies do not cover CGM products. However, she has the option of selecting a CGM product and paying out of pocket if her insurance company doesn’t cover it. According to Healthline, direct prices for CGM supplies can range from $ 160 to $ 500 per month.2
Case 2: Diabetes Neuropathic pain
Question: RM is a 58-year-old woman who complains of neuropathic pain related to diabetes. She has had diabetes for 15 years and her A1C level is usually between 9 and 10. RM takes 1000 mg of metformin twice a day but does not want to add more prescription drugs. Her doctor recently diagnosed her with neuropathic pain, but she refused to add medication at the time. RM’s friend said she started taking alpha lipoic acid, which helped reduce her pain. RM is hesitant to add a supplement because of her concerns about drug interactions. What recommendations should the pharmacist make?
A: RM should discuss adding alpha lipoic acid with his prescriber. One study followed 460 patients for 4 years and found alpha lipoic acid to be helpful in preventing the progression of neuropathy.3 MR could benefit from adding alpha lipoic acid to prevent further progression. A meta-analysis evaluated the addition of alpha-lipoic acid and found improvements in neuropathic pain, when given intravenously. The study authors concluded that the benefit of oral administration is unclear.4 RM can see if this is beneficial, but should also be aware that there are several prescription drugs that may also be of benefit for diabetic neuropathy.
Case 3: Diabetes Cold
Question: CS is a 38 year old man seeking pseudoephedrine to relieve his congestion. CS has been ill for 2 days with some congestion, but he has no cough or fever. His medical history includes diabetes and hypertension. CS takes 10 mg of lisinopril per day, 1000 mg of metformin twice a day and 10 U of regular insulin with each meal. He has no seasonal allergies and has not tried any medication to relieve his congestion. What recommendations should the pharmacist make?
A: All over-the-counter decongestants come with a warning label for patients with diabetes or hypertension.5 Pseudoephedrine can increase blood pressure (BP), so patients are recommended to monitor their BP while taking a decongestant. In addition, diabetic patients on insulin should monitor their BP more often and adjust anti-diabetic drugs if necessary.6 In addition to using a nasal decongestant, CS may consider trying a dehumidifier or nasal saline to see if her congestion improves.
Case 4: Diabetes and smoking cessation
Question: YI is a 45 year old man who wants to quit smoking. He has smoked 2 packs of cigarettes a day for 15 years. YI tried to stop the cold turkey a few times but never succeeded. He has diabetes and takes 1000 mg of metformin twice a day and 20 U of regular insulin with each meal. YI would like information on over-the-counter nicotine replacement products, such as the patch. What advice should the pharmacist give him?
A: Nicotine replacement products have been of benefit to patients trying to quit smoking. Because YI smokes 2 packets per day, her recommended dose would be 21 mg for 4-6 weeks, followed by 14 mg for 2 weeks and 7 mg for an additional 2 weeks. The most common side effects associated with the patch are skin reactions, such as burning or redness. I need to apply the patch to a clean, dry area on the upper arm or body every 24 hours. The patch should be applied to a different part of the skin each day to avoid skin reactions. A patch should not be used for more than 24 hours. YI can shower and swim with the patch.7 Let him know. that when he quits smoking he should monitor his blood sugar more often, because nicotine can affect the cells that block the action of insulin and hypoglycemia can occur.8 YI may also receive additional support by participating in community smoking cessation support groups.
Rupal Patel Mansukhani, PharmD, FAPhA, NCTTP, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers, State University of New Jersey at Piscataway, and a clinical pharmacist specializing in transitions of care at Morristown Medical Center in New Jersey.
Ammie J. Patel, PharmD, BCACP, BCPS, is Clinical Assistant Professor of Pharmacy Practice and Administration at the Ernest Mario School of Pharmacy at Rutgers, State University of New Jersey at Piscataway, and Ambulatory Care Specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.
1. Better blood glucose meters and more. American Diabetes Association. Accessed August 20, 2021. https://www.diabetes.org/healthy-living/devices-technology
2. Hoskins M. Buy CGM (Continuous Blood Glucose Monitor) supplies at the drugstore. Health line. April 3, 2021. Accessed August 22, 2021.https: //www.healthline.com/diabetesmine/cgm-access-pharmacies
3. Ziegler D, Low PA, Litchy WJ, et al. Efficacy and safety of antioxidant treatment with alpha-lipoic acid over 4 years in diabetic polyneuropathy. Diab Care. 2011; 34: 2054-2060. doi: 10.2337 / dc11-0503
4. Mijnhout GS, Kollen BJ, Alkhalaf A, Kleefstra N, Bilo HJG. Alpha-lipoic acid for symptomatic peripheral neuropathy in diabetic patients: a meta-analysis of randomized controlled trials. Intl J Endocrinol. 2012: 456279. doi: 10.1155 / 2012/456279
5. Soudafé. SUDAFED sinus congestion. Accessed August 20, 2021.https: //www.sudafed.com/products/sudafed-sinus-congestion
6. Drug interactions between Contac Day and Night Cold and Flu and insulin.Drugs.com. Accessed August 24, 2021. https://www.drugs.com/drug-interactions/contac-day-and-night-cold-and-flu-with-insulin-52-10276-1340-0.html
7. Nicotine replacement therapy to help you quit smoking. American Cancer Society. Updated August 2, 2021. Accessed August 20, 2021. https://www.cancer.org/healthy/stay-away-from-tobacco/guide-quitting-Smoking/nicotine-replacement-therapy.html
8. Smoking and diabetes. CDC. August 10, 2021. Accessed August 22, 2021. https://www.cdc.gov/diabetes/library/features/Smoking-and-diabetes.html