Diabetes Awareness Month – The emerging role of the pharmacist in remission of Type 2 diabetes

The Institute for Personalized Therapeutic Nutrition[i] (IPTN) defines Therapeutic Nutrition as an individually tailored nutritional intervention designed to manage or reverse patient specific metabolic dysfunctions, medical conditions or their associated symptoms. This concept of taking a ‘food first’ approach to treating type 2 diabetes provides new evidence-based options for patients and health care providers to consider. However, Therapeutic Nutrition requires clinical oversight, and needs to be personalized to the patient and their condition(s). Health care professionals must understand the impact of Therapeutic Nutrition to avoid predictable adverse events, as medications often need to be reduced or discontinued as a patient’s metabolic health improves. Pharmacists are especially well positioned to provide this oversight as part of an interdisciplinary team-based approach.

A growing body of research is demonstrating that therapeutic carbohydrate restriction, one form of Therapeutic Nutrition, can improve metabolic function and even put type 2 diabetes into remission. The resulting evidence is reflected in recent published changes to international diabetes guidelines, including the American Diabetes Association Standards of Care for 2020, which recognizes carbohydrate restriction as a viable treatment option for select patients.

An example of such research is an innovative study conducted from 2017 – 2019 by the University of BC, the IPTN and Pharmasave. This randomized clinical trial examined the impact of a 12-week pharmacist-led therapeutic nutrition intervention on medications and glucose control in close to 200 patients with type 2 diabetes. The role of these specially trained pharmacists in 12 community pharmacies across BC was to a.) address patient safety by preventing hypoglycemia and hypotension b.) monitor patient responses and proactively address potential risks c.) assist physicians to prioritize which medications to reduce and when and d.) communicate with the health care team about medication changes and patient progress. The results were very dramatic with patient having to reduce or eliminate glucose lowering medication, including high doses of insulin, often within days of starting. In fact, close to two-thirds of patients who started the study on insulin had to have it discontinued, typically within the first couple of weeks.

As the standard of diabetes care evolves to include Therapeutic Nutrition approaches, and interdisciplinary team-based care becomes the delivery model of the future, there will be implications and opportunities for community pharmacists. All pharmacists will need to have the knowledge and skills to counsel and consult on medication management for patients who choose these dietary approaches to prevent predictable medication related adverse events. Patients and payers are already very interested in reducing medication use, and patient awareness of diabetes remission will drive demand for these new services. Referral based Community Deprescribing and Diabetes Remission Centres are just around the corner and pharmacists are well positioned to become leaders for practice change in this new frontier.