University Times

As a pharmacist, Scott Drab says those in his profession should be playing a larger role in controlling the diabetes epidemic. And he’s done something about it.

Drab is assistant professor of pharmacy and therapeutics in the School of Pharmacy and the founder and director of University Diabetes Care Associates, one of the first pharmacist-run diabetes care centers located in a community pharmacy.

Pharmacists already are involved heavily in drug management for diabetics, who typically take six-eight medications, said Drab, a certified diabetes educator (CDE).

“The problem of diabetes is going to get bigger and we don’t have enough health care professionals to treat it, or at least we don’t have access to enough health care professionals to see all these people,” Drab said.

To get an appointment with an endocrinologist, the specialist a diabetic usually sees, a patient might have to wait three-six months, he noted. “But think about pharmacists. There’s a pharmacy on every corner. This is the most accessible health care professional out there. So it makes sense from my standpoint to train pharmacists, and to expand the role of pharmacist CDEs,” he said.

While using a health care team to treat patients is not a new concept, integrating it into the academic training of the pharmacist is, Drab said.

Scott Drab

“We have to know our limitations, too. A patient will come in wanting more information on meal planning when they’re dining out, or on what exercises work best, so we have to know when to refer patients to exercise therapists or dieticians.”

Drab has established a collaborative care model at his diabetes care pharmacy in Jeannette. He works with some 40 local physicians who refer patients to him for everything from basic diabetes education and blood glucose monitor training to solving complex pharmacotherapy problems.

“Patients come in and have a full evaluation meeting. We do the basic vitals of blood pressure, weight,” said Drab, whose clinic follows some 20-30 patients a day. The pharmacy’s staff includes a registered dietician who is a certified diabetes educator, a nurse CDE, an exercise physiologist and a handful of School of Pharmacy students on rotation.

“Many of these patients are not well-controlled and the physicians are looking now to the pharmacist CDE for assistance,” Drab said, noting the vast number of diabetes medications, some of which target certain aspects of diabetes better than others.

“The physicians want us to help them through this myriad maze of pharmacotherapy to ensure that the patient is on the appropriate drugs, is getting adequate glucose control and ultimately to reduce complications and morbidity and mortality,” he said.

Drab can prescribe and adjust medications, something that is spelled out in the individual practice agreements with the physicians, he said.

“Twenty-five years ago when I was in practice, we had physicians telling us not only what drug they wanted, but they actually went so far as to tell us how to dispense it,” Drab said. “The other day, I had a physician refer his wife to me, and I asked her, ‘What medication did your husband put you on?’ She said: ‘Nothing. He said you would put me on something.’ That’s a paradigm shift. There’s a respect there. There’s a trust there. I see that as a good thing,” he said.

At Pitt, Drab’s responsibilities involve both clinical instruction and classroom teaching. He has been part of the pharmacy school’s increased emphasis on diabetes.

“When I first came here in 1996, we probably had two or three lectures on diabetes,” Drab said. Now, the study of diabetes consumes one-third of the semester-long endocrinology course. “And it’s much more hands on. We have patients come in to talk about their experience with diabetes,” and students learn to understand the disease from the patient’s perspective, he said.

Pitt’s curriculum also includes extensive meter and insulin injection training sessions, where manufacturers demonstrate proper use of their equipment. Thus, “the ability to recommend an appropriate monitor to a patient is greatly increased,” he said.

Students also have required experiential assignments, where they identify patients at their community practice site who are not getting proper glucose control and form a treatment action plan.

Much of this type of training is atypical at pharmacy schools, Drab added.

Pitt’s school also offers a comprehensive diabetes management elective course for pharmacists who want advanced training. The course, which lays the foundation for certified diabetes educator certification, covers everything from basic patho-physiology to drug review, as well as medical nutrition therapy, diet and exercise physiology. It also covers complications and patient education and focuses on special populations with diabetes, such as the elderly, adolescents and pregnant women.

Yet there still is much to learn about diabetes as researchers, health practitioners and diabetics themselves learn better ways to prevent, manage and treat the disease, Drab noted. However, he doubts that science will develop a way to cure those who develop diabetes.

“We can administer insulin and replace the hormone that has gone awry. Patients who are well-controlled tend to avoid complications. But is there a way where we can flip a switch, give someone a tablet and the whole thing goes away like it never happened? That’s never going to happen, in my view,” Drab said.

“What I think we’ll see in the future are developments in technology such as the artificial pancreas, which is an insulin pump that is implanted under the skin along with a continuous glucose monitor. And it works for both Type 1 and Type 2 diabetes,” he said.

The first insulin pump was the size of a backpack; today’s version is the size of a pager.

Drab also anticipates increased efforts to prevent the disease. “There are prevention strategies out there. There are also medications that can reduce your risk of getting diabetes,” Drab said. “Certainly lifestyle modification — diet and exercise — is better. But what happens if we put the two together? We’re going to have to think about drug therapy also in the prevention realm,” he said.

“We need to do a better job of preventing diabetes, a better job of identifying it earlier. We do need to be a little more aggressive in our treatment, and we need to have better access to health care professionals who are trained in this disease that can also offer earlier care and continual care,” Drab said.

“If you look at the health outcomes data, what they show us is that the traditional physician-driven model has not yielded too terribly great results in the area of diabetes. Yes, we’ve seen improvements in diabetes care, but there’s still probably 40-45 percent of all diabetics out there who are not achieving adequate control,” he said. “So we need to move toward a more collaborative model and, most importantly, we need to increase access to health care.”