Pharmacist intervention can lead to safer prescribing in type 2 diabetes

Severe hypoglycemia is a potentially life-threatening complication of diabetes medications. It is associated with increased risks of falls, cardiovascular events, cognitive decline and mortality, and contributes substantially to healthcare utilization and cost. Several studies have shown that deintensification of hypoglycemia-prone regimens, particularly sulfonylureas and insulin, can reduce hypoglycemia risk without compromising glycemic control. Previous interventions to reduce diabetes medication risk have focused on clinician and/or patient education, but published studies of proactive, guideline-based, pharmacist-led interventions are lacking. To address this gap, U.S. researchers first developed an evidence-based, hypoglycemia-prevention algorithm to support safer diabetes medication management. The algorithm provides guidance on medication regimen changes, glycemic target resetting, use of continuous glucose monitoring, glucagon prescribing, tailoring patient education, and adding hypoglycemia to the patient’s problem list. The researchers then conducted a randomized clinical trial to evaluate whether proactive clinical pharmacist outreach, guided by the algorithm, would increase the proportion of patients with type 2 diabetes and high hypoglycemia risk who were prescribed safer diabetes regimens compared with usual care. The authors hypothesized that pharmacist intervention would result in more frequent deprescribing of hypoglycemia-prone agents without worsening glycemic control and would reduce hypoglycemia-related emergency department and inpatient visits.The randomized clinical trial was conducted in a large, integrated healthcare delivery system in Northern California over a six-month period, with follow-up over the subsequent year. The study included adults with type 2 diabetes at high risk of hypoglycemia based on a validated hypoglycemia risk tool. Approximately 50% of patients in this study had experienced a hypoglycemia-related emergency department or inpatient visit in the past 12 months. Patients were randomized 1:1 to either a protocol-driven outreach by a clinical pharmacist (intervention arm) or usual care (control arm). The intervention was delivered by a pharmacist with clinical diabetes expertise. The pharmacist reviewed intervention-arm patient medical records, obtained primary care team approval to contact the patient, and then conducted proactive outreach. Initial telephone encounters (45 minutes) assessed the patient’s hypoglycemia history, risk factors, medication use and glycemic data. Guided by the algorithm, the pharmacist set individualized glycemic targets; optimized medications (discontinuing sulfonylureas, mealtime [bolus] insulin, or mixed insulin when appropriate); provided education on hypoglycemia prevention and treatment; and made health education, nutrition or social services referrals as needed. Follow-up calls (15–30 minutes) occurred every one to four weeks until hypoglycemia resolved, based on patient-reported symptoms, in addition to review of blood glucose levels. The main outcome of the study was the proportion of patients who were prescribed safer (less hypoglycemia-prone) diabetes regimens (defined as discontinuation of sulfonylureas and/or rapid-acting or short-acting or mixed insulins) in the intervention versus usual care group.Key results:200 patients were enrolled into the clinical trial; after further exclusions, the cohort included 191 patients (96 intervention, 95 usual care; mean age 71.3 years; 52.4% female).The two study arms were similar at baseline in terms of race and ethnicity, sex, mean glycated hemoglobin (A1C) level (intervention: 8.0%; control: 8.3%), number of patients receiving insulin (intervention: 82 [85.4%]; control: 85 [89.5%]) and number of patients receiving a sulfonylurea (intervention: 25 [26.0%]; control: 21 [22.1%]).At six months, patients in the intervention arm were more likely to be prescribed a safer diabetes regimen than those in the control arm (27 [28.1%] vs 15 [15.8%]; risk difference [RD], 12.3% [95% CI, 0.6%–24.0%]).Patients in the intervention arm also experienced significantly fewer hypoglycemia-related emergency department or inpatient visits (0 vs 5 [5.3%]; RD, −5.3% [95% CI, −11.8% to −1.3%]).No worsening of A1C was seen in the intervention arm compared with the control arm (47 [61.8%] vs 49 [63.6%] with A1C < 8%; RD, −1.8% [95% CI, −17.0% to 13.5%]).The researchers conclude that in this randomized clinical trial, patients in the pharmacist-led intervention arm were approximately twice as likely as those in the usual care arm to be prescribed a safer diabetes regimen at six months (28.1% vs 15.8%). The authors maintain that adding proactive, protocol-driven clinical pharmacist outreach into collaborative team-based care provides an evidence-based approach for reducing the risk of developing severe hypoglycemia in individuals with type 2 diabetes, enhancing patient safety and potentially reducing overall healthcare costs. This effective scalable strategy can reduce treatment-related harm in type 2 diabetes populations at high risk.The authors comment that they conducted a separate (unpublished) study to assess whether dissemination of the new hypoglycemia algorithm alone to physicians was associated with a reduction in rates of emergency department visits and hospitalizations for hypoglycemia. They did not detect a significant effect, suggesting that dissemination of an algorithm alone, without proactive identification and outreach to patients at risk, may not change prescribing patterns of diabetes physicians. The results of this study support expanding team-based care models to incorporate protocol-driven, proactive pharmacist outreach for type 2 diabetes patients at high risk of hypoglycemia.ReferenceGilliam LK, Parker MM, Chen MW, et al. Pharmacist intervention for safer prescribing in patients with type 2 diabetes at high risk. A randomized clinical trial. JAMA Netw Open 2026;9;(2):e2559946. Published online: February 18, 2026. (accessed February 24, 2026).

Pharmacist intervention can lead to safer prescribing in type 2 diabetes

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