A Closer Look at the Ambulatory Care PRN
Overview of the PRN
The Ambulatory Care PRN is composed of pharmacists from a diverse array of outpatient settings, with a particular emphasis on pharmacists who provide primary care for chronic diseases. One of the first two PRNs established in 1992, the Ambulatory Care PRN has grown to be one of the largest PRNs each year. The PRN has around 1800 active members, including over 400 student, resident, and fellow/graduate members. The PRN maintains an active e-mail list, where clinicians and trainees discuss breaking research and share advice regarding practice development.
Opportunities and Resources
The Ambulatory Care PRN consists of clinical pharmacists, postgraduate trainees, and students interested in ambulatory care across all practice settings. To make it one of the premier PRNs, the PRN has several committees that work throughout the year, including Advocacy, Budget, Communications, Education, Membership, Networking, Nominations, Research Process, Scholarly Activity, Resident/Fellow, and Student. All trainees are welcome and encouraged to join committees, which expose trainees to various areas of PRN activities, foster ambulatory care as a practice interest, and encourage future participation in the PRN.
Following are highlights of some of the opportunities provided to the PRN’s student, resident, and fellow members:
PRN Travel Awards: Up to five travel awards are given to both student and resident/fellow members of ACCP to help support attendance at the Annual Meeting. Applications for the 2022 Annual Meeting will open in June. More information will be posted on the ACCP website closer to the submission date. The awards are funded by the Ambulatory Care PRN budget.
Ambulatory Care PRN Mentoring Programs: The PRN hosts student and resident/fellow mentorship programs. These programs allow trainees to be paired with ambulatory care clinicians. They also foster discussions about career development, networking, leadership, and other topics relevant to professional development. Student and resident/fellow benefits include:
- Growing a professional network by getting to know practitioners within ambulatory care
- Gaining new knowledge and skills in career advancement
- Getting more involved in ACCP and the Ambulatory Care PRN
Access to mock residency interviews and interviews with residency program directors: Trainees have access to a mock interview showing the difference between a “good” interview and an “excellent” interview. They also have access to recorded interviews with residency program directors who provide insight on what residencies are looking for in a resident.
Access to the Ambulatory Care Pharmacist’s Survival Guide: The survival guide provides information on clinical questions, together with advice on practice management in a variety of practice settings.
Other benefits of joining the PRN include:
- Ambulatory Care e-mail list and PRN directory
- Eligibility for research funding
- Innovation grant funding and PRN seed grants
- Academy sponsorships
- BCACP and BCPS study groups
- New member recognition spotlight
- Access to webinars, expert-facilitated roundtables, and other resources to develop and sustain an ambulatory care practice
- Publication and scholarly opportunities
- Best Poster Awards for the virtual Poster Symposium and Annual Meeting
- Advocacy opportunities and events
- Advising the PRN leadership regarding financial decisions, setting the budget, and prioritizing the PRN initiatives important to supporting trainees
- Networking events, including a planned event at the Annual Meeting
- Writing Coach Program
- Writing to accountability partners and encouragement to participate in the #RxWritingChallenge
All students, residents, and fellows are encouraged to follow the PRN on social media:
Facebook: ACCP Ambulatory Care PRN
Current Issue: Comprehensive Medication Management
ACCP is a member organization of the Get the Medications Right (GTMRx) Institute and has been working with GTMRx to expand comprehensive medication management (CMM) in clinical practice around the country. CMM is a patient-centered approach to medication use that includes an ongoing and continuous assessment of the patient’s clinical status and social determinants of health. CMM is usually delivered by a pharmacist in collaboration with the health care team, which aims to standardize the wide variability in medication-specific pharmacist-led services to optimize medication use and improve clinical outcomes. CMM is defined as “the standard of care that ensures each patient’s medications (i.e., prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended.”1 This approach encourages collaboration with other providers to create an individualized care plan that meets intended targets and achieves desired outcomes. Care is coordinated across settings, and pharmacists are responsible for providing ongoing assessments, redesigning care plans as necessary, and providing continuous coordination with other providers to ensure patients have follow-ups specific to their medication-related needs and individualized goals of therapy are achieved.
The following publications provide additional insight and education about GTMRx and CMM:
1. American College of Clinical Pharmacy (ACCP). Comprehensive Medication Management in Team-Based Care. Available at CMM Brief.pdf (accp.com).
Current Issue: Use of Glucagon-Like Peptide-1 Receptor Agonists in Patients with a History of Pancreatitis
By: Caressa Trueman, Pharm.D., BCACP; and Natalie Tiefenthaler, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident at Nebraska Medicine
Type 2 diabetes (T2DM) is caused by multiple hormonal imbalances and organ system deficits, currently known as the “egregious 11.”1 Over the past 2 decades, several new classes of antidiabetic pharmacotherapies have been developed to target these imbalances, with glucose-like peptide-1 receptor agonists (GLP-1 RAs) emerging as one of the most powerful. In initial trials, these agents had a low hypoglycemia risk, a potential for weight loss, and an average A1C reduction of 0.8%–1.5%.2 As time elapsed, once-weekly agents were released alongside additional evidence for reduced cardiovascular risk AND delayed development/progression of diabetic kidney disease.3 Thus, GLP-1 RAs have become a backbone of the diabetes management landscape.
However, these game changers also have adverse effects, including the potential risk of pancreatitis. Package labeling states that these medications have not been studied in patients with a history of pancreatitis and recommends using alternative antidiabetic therapies.4 Of interest, the link between incretin-based therapies like GLP-1 RAs and pancreatitis was not initially observed in clinical trials; rather, it was discovered through postmarketing reports. In fact, all manufacturer-sponsored trials, including the more recent cardiovascular outcomes trials, have excluded patients with a history of pancreatitis. In 2009, the FDA mandated that package labeling for all incretin-based therapies include warnings of pancreatitis. Despite the hype surrounding this potential, the mechanism is not well understood or validated. The current theory detailed by Thomsen et al. is that GLP-1 receptor agonism in pancreatic islet beta cells and exocrine duct cells causes an overgrowth of cells that cover the smaller ducts. This results in hyperplasia, increased pancreatic weight, duct occlusion, back pressure, and subsequent acute or chronic pancreatic inflammation.5
In addition to the lack of a validated mechanism between GLP-1 RAs and pancreatitis, a diagnosis of diabetes itself carries a risk of developing pancreatitis. Many studies have shown that people with diabetes are up to 3 times more likely to develop pancreatitis than individuals without diabetes.6 Consequently, the increased risk of pancreatitis secondary to diabetes has led many to dispute the association between GLP-1 RAs and pancreatitis.
Along these lines, several studies have been published to prove or disprove the link between incretin-based therapies and pancreatitis. In a meta-analysis evaluating the adverse event incidence of acute pancreatitis in the cardiovascular outcome trials for GLP-1 RAs, Singh and colleagues found that adding GLP-1 RAs to the therapeutic regimen of patients at high cardiovascular risk did not increase the risk of pancreatitis.7 To further assess the relationship between patients with diabetes and pancreatitis, Faillie et al. compared incretin-based therapies with sulfonylurea therapies and evaluated the incidence of pancreatitis.8 This study found no difference between the incidence of acute pancreatitis in patients treated with these two classes of medications, adding further evidence that the underlying disease is likely the cause of pancreatitis, not the drug class itself.
These findings discredit the proposed causality between the GLP-1 RA medication class and pancreatitis. Given this lack of established association in many clinical trials, the American Diabetes Association does not recognize the causal relationship between GLP-1 RAs and pancreatitis.3
In practice, however, many practitioners turn to clinical judgment when assessing the use of GLP-1 RAs in patients with a history of pancreatitis, given the sparce evidence provided by clinical trials. When reviewing the potential adverse effects of GLP-RAs with patients, practitioners should stress that the risk of developing pancreatitis is low. However, patients should be educated to monitor for signs and symptoms of acute pancreatitis, such as upper abdominal pain that may radiate to the back, abdominal tenderness, fever, nausea, and vomiting.9 Although as of February 2022, there were no published guidelines or recommendations for monitoring for pancreatitis, the American Diabetes Association guidelines on lipid management note that providers and pharmacists should be instructed to monitor an annual lipid panel for patients older than 40 taking lipid-lowering therapy.10 If there are concerns for pancreatitis, this laboratory test can be repeated more often.
In summary, as long as the precipitating risk factor for pancreatitis has been controlled or diminished, the use of GLP-1 RAs in patients with a history of pancreatitis is safe, with a recommendation for increased patient monitoring and awareness.
- Schwartz SS, Epstein S, Corkey BE, et al. The time is right for a new classification system for diabetes: rationale and implications of the β-cell–centric classification schema. Diabetes Care 2016;39:179-86.
- Prasad-Reddy L, Isaacs D. A clinical review of GLP-1 receptor agonists: efficacy and safety in diabetes and beyond. Drugs Context 2015;4:1-19.
- American Diabetes Association Professional Practice Committee. 9. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes – 2022. Diabetes Care 2022;45(suppl 1):S125-S143.
- Ozempic (semaglutide) [prescribing information]. Novo Nordisk.
- Thomsen RW, Pedersen L, Møller N, et al. Incretin-based therapy and risk of acute pancreatitis: a nationwide population-based case-control study. Diabetes Care 2015;38:1089-98.
- Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology 2013;144:1252-61.
- Singh AK, Gangopadhyay KK, Singh R. Risk of acute pancreatitis with incretin-based therapy: a systematic review and updated meta-analysis of cardiovascular outcomes trials. Expert Rev Clin Pharmacol 2020;13:461-8.
- Faillie JL, Azoulay L, Patenaude V, et al. Incretin-based drugs and risk of acute pancreatitis in patients with type 2 diabetes: cohort study. BMJ 2014;348:g2780.
- National Institute of Diabetes and Digestive and Kidney Diseases. Symptoms and Causes of Pancreatitis. Updated November 2017. Available at https://www.niddk.nih.gov/health-information/digestive-diseases/pancreatitis/symptoms-causes.
- American Diabetes Association Professional Practice Committee. 10. Cardiovascular disease and risk management: Standards of Medical Care in Diabetes – 2022. Diabetes Care 2022;45(suppl 1):S144-S174.
Current Issue: Expanding Access to Continuous Glucose Monitoring for Patients with Type 2 Diabetes
By: Riley J. Larson, Pharm.D., PGY1 Ambulatory Care Pharmacy Resident at the University of Minnesota
The role of continuous glucose monitoring (CGM) in optimizing the care of individuals with type 2 diabetes (T2DM) is expanding, especially in the primary care setting. CGM paints a complete picture of glycemic management by analyzing interstitial glucose concentrations every 1–5 minutes. Lifestyle modifications are critical to aid in managing T2DM, and CGM can be instrumental in helping patients better understand how to manage blood glucose when performing different activities.1 For example, patients can visualize firsthand how a walk or other moderate-intensity activity can affect their glucose readings. In addition, patients can witness in real time how different foods are affecting their readings. Emerging literature suggests that these visualizations can motivate patients to make dietary changes – often, in many cases, decreasing insulin use and subsequent cost of care.2-4 Furthermore, CGM promotes patient safety by constantly monitoring for hypoglycemia.1 With newer devices, an alarm notifies the patient to take the appropriate action.
Despite advances in technology and demonstrated improvements in care, explicit yet complicated prior authorization criteria impede access to these devices, especially for patients with T2DM taking less than three doses of insulin per day (e.g., patients treated with basal insulin alone). However, clinical practice guidelines and large meta-analyses have confirmed the usefulness of CGM in patients with type 1 diabetes and type 2 diabetes taking more than three doses of insulin per day.1,5-9
Before 2020, the literature was limited on the usefulness of CGM in patients with T2DM treated with basal insulin or non-insulin therapy; however, recent randomized trials and cohort studies have begun to support the use of CGM in this group of patients, prompting updates to key clinical practice guidelines. Moreover, the American Diabetes Association 2022 clinical practice guidelines have expanded recommendations for CGM for patients with T2DM using basal insulin regimens, stating that CGM “can be used for diabetes management in adults with diabetes on basal insulin who are capable of using devices safely.”1 In addition, the American Association of Clinical Endocrinology and American College of Endocrinology (AACE/ACE) T2DM treatment algorithm states that CGM is preferred to blood glucose monitoring (BGM) and is highly recommended to help all patients with T2DM reach glycemic goals safely.8 Furthermore, AACE/ACE recently published a diabetes technology guideline specifically recommending CGM for patients with T2DM treated with “less intensive insulin therapy” or any patient with diabetes who experiences problematic hypoglycemia.9
One paramount 2021 pilot randomized controlled trial comparing CGM with BGM in patients with T2DM using basal insulin found a statistically significant reduction in A1C favoring the CGM group after 8 months (-1.1% vs. -0.6% in the CGM and BGM groups, respectively; p<0.001).2 Of note, patients were only recruited from primary care settings, which is reflective of how diabetes is managed in the real world, given that about 80% of patients are treated in primary care settings. Another small pilot randomized trial compared BGM with CGM for patients with T2DM using only non-insulin therapies.3 Baseline A1C was 8.3% in the BGM group and 8.4% in the CGM group. After 12 weeks of only lifestyle changes, 34.1% of patients in the CGM group and 17.4% in the BGM group achieved an A1C less than 7.5%. Although there was not a statistically significant difference between the two groups, this study laid the groundwork for larger studies examining the usefulness of CGM in patients treated with non-insulin therapies.
Pharmacists can play a pivotal role in optimizing drug therapy using CGM data together with their expertise in the mechanism of action, pharmacokinetics, and pharmacodynamics of medications. Although the literature is limited in identifying the pharmacist’s role in using personal (patient owned) CGM, recent studies discuss their role in professional (clinic owned) CGM.4,10,11 Specifically, a 2021 Veterans Affairs retrospective study examined pharmacist-driven professional CGM implementation in patients with T2DM. Six months after implementation, patients had about a 1% reduction in A1C (p=0.006).4 These studies serve as a foundation for further research on the pharmacist’s role in personal CGM as coverage expands.
These guideline updates and recent trials have pressured payers to expand coverage for CGM devices. As of July 2021, Medicare lifted the requirement for documentation of four-times-daily fingerstick BGM to qualify for CGM.12 However, the requirement for three-times-daily injections still exists. In Minnesota, Medicaid plans have expanded coverage for CGM for all patients with diabetes, regardless of type.13 Ideally, studies examining this change in Minnesota will prompt other payers to follow a similar path.
In conclusion, further exploration of the clinical usefulness of CGM in patients with T2DM, specifically those using basal insulin or non-insulin agents alone, is warranted to help expand access to these useful devices.
- American Diabetes Association Professional Practice Committee, Draznin B, Aroda VR, et al. 7. Diabetes technology: Standards of Medical Care in Diabetes – 2022. Diabetes Care 2022;45(suppl 1):S97-S112.
- Martens T, Beck RW, Bailey R, et al. Effect of continuous glucose monitoring on glycemic control in patients with type 2 diabetes treated with basal insulin: a randomized clinical trial. JAMA 2021;325:2262-72.
- Price DA, Deng Q, Kipnes M, et al. Episodic real-time CGM use in adults with type 2 diabetes: results of a pilot randomized controlled trial. Diabetes Ther 2021;12:2089-99.
- Ulrich H, Bowen M. The clinical utility of professional continuous glucose monitoring by pharmacists for patients with type 2 diabetes. J Am Pharm Assoc (2003) 2021;61:e76-e82.
- Dicembrini I, Cosentino C, Monami M, et al. Effects of real-time continuous glucose monitoring in type 1 diabetes: a meta-analysis of randomized controlled trials. Acta Diabetol 2021;58:401-10.
- Evans M, Welsh Z, Ells S, et al. The impact of flash glucose monitoring on glycaemic control as measured by HbA1c: a meta-analysis of clinical trials and real-world observational studies. Diabetes Ther 2020;11:83-95.
- Ida S, Kaneko R, Murata K. Utility of real-time and retrospective continuous glucose monitoring in patients with type 2 diabetes mellitus: a meta-analysis of randomized controlled trials. J Diabetes Res 2019;2019:4684815.
- Garber AJ, Handelsman Y, Grunberger G, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm – 2020. Endocr Pract 2020;26:107-39.
- Grunberger G, Sherr J, Allende M, et al. American Association of Clinical Endocrinology clinical practice guideline: the use of advanced technology in the management of persons with diabetes mellitus. Endocr Pract 2021;27:505-37.
- Sherrill CH, Houpt CT, Dixon EM, et al. Effect of pharmacist-driven professional continuous glucose monitoring in adults with uncontrolled diabetes. J Manag Care Spec Pharm 2020;26:600-9.
- Benedict AW, Spence MM, Sie JL, et al. Evaluation of a pharmacist-managed diabetes program in a primary care setting within an integrated health care system. J Manag Care Spec Pharm 2018;24:114-22.
- American Diabetes Association (ADA). New Medicare Coverage Requirements Make CGMs More Accessible. July 2021. Available at https://www.diabetes.org/tools-support/devices-technology/cgm-medicare-coverage-requirement-change-accessibility.
- Department of Human Services. Minnesota Fee-for-Service and Managed Care Medicaid Uniform Preferred Drug List. January 2022. Available at https://mn.gov/dhs/assets/preferred-drug-list-2022-01-01_tcm1053-514311.pdf.