Glucagon Like Peptide 1 Receptor Agonists (GLP-1 RA) are a novel drug class used in the management of type 2 diabetes due to their glucose-lowering, weight-loss and cardiovascular benefits.
The Scottish Intercollegiate Guidelines Network (SIGN) recommends GLP-1 RAs to be considered in those with type 2 diabetes who have a BMI ≥ 30 kg/m2 in combination with oral glucose-lowering drugs or basal insulin (or both) as third- or fourth-line treatment, when glycaemic control is not at target.
GLP-1 RA therapy should be considered as an alternative to insulin in people for whom treatment with combinations of oral glucose-lowering drugs has been inadequate. Also, GLP-1 RAs with proven CV benefits should be considered in patients with type 2 diabetes and established cardiovascular disease.
Despite the vast benefits of GLP-1 RAs, local NHS board prescribing data from 2017 has shown their utilisation is below the Scottish average despite at least 43 percent of patients with type 2 diabetes having a BMI ≥ 30 kg/m2 and the percentage of patients with a HbA1c ≥75mmol/mol was just below the Scottish average: 12.8 percent vs. 14.1 percent.
Furthermore, the percentage of patients who had macrovascular complications such as an MI or stroke was above the Scottish average.
The low GLP-1 RAs prescribing rates may be due to a few reasons. According to the local formulary, GLP-1 RAs are consultant initiation only and therefore are not regarded as a primary care initiation drug. In addition, from 2016 to 2018, the waiting time for an outpatient appointment to see a consultant diabetologist at a secondary care clinic in the local NHS board was long; the endocrinology and diabetes department was one of the two specialities who had the lowest compliance (38 percent) against the 18 weeks referral to treatment target of 90 percent.
It was clear that there was a gap in patient care and therefore a pharmacist was integrated into the GP practice team in order to deliver this first of its kind service within the local health board. GLP-1 RA therapy was offered to patients with type 2 diabetes who attended a diabetes review at the GP practice and fulfilled the criteria as described by the SIGN guidelines at a local, easily accessible GP practice.
At the pharmacist-led clinic, the patients were followed up on Week 1 and Week 3 post-initiation via telephone call and at three-month and six-month post-initiation to check concordance, HbA1c, weight, any adverse effects and blood sugars if the patient was on concomitant sulfonylurea and/or insulin.
The information that was covered with the patient at the point of GLP-1 RA initiation included:
- Information discussed with patient
- Dosing and mode of action of the GLP-1 RA
- Correct use of the GLP-1 RA pen
- Injection site rotation
- Disposal of pen/sharps
- Side effects
- Storage of the GLP-1 RA pen
- Individualised HbA1c and weight targets
- Dietary advice
- Safely reduce insulin doses without increasing risk of diabetic ketoacidosis if patient was already on insulin
- Access to anti-emetics if required.
The risk of miscommunication of any treatment plan was reduced as the pharmacist kept an audit of all patients on GLP-1RAs to ensure they were titrated to the appropriate dose in a timely manner and that the GLP-1 RA was only continued if there were metabolic benefits at six months post-initiation of GLP-1 RA.
At the time of writing, 36 patients have been initiated on GLP-1 RA therapy:
- Twenty four patients (66 percent) achieved their HbA1c target and weight reduction target within six months of starting GLP-1 RA.
- Two patients achieved their HbA1c target but not their weight reduction target within six months of starting GLP-1 RA.
- One patient achieved their weight reduction target but not their HbA1c target within six months of starting GLP-1 RA.
- One patient did not achieve their weight reduction target or their HbA1c target within six months of starting GLP-1 RA.
- Eight patients (22 percent) were just initiated on GLP-1 RA and therefore their results were not included.
Those patients who had treatment failure with the GLP-1 RA were then initiated on to insulin or combination of insulin/GLP-1 therapy.
This service improved access and outcomes as the pharmacist offered GLP-1 RA therapy to patients with type 2 diabetes who attended a diabetes review at the GP practice and fulfilled the criteria as described by the SIGN guidelines. This in turn led to successfully addressing inequalities and improving patient care and outcomes, reducing waiting times for secondary care appointments, reducing the risk of delayed prescriptions, minimising referrals and most importantly, improving equity of access. Patients were initiated on GLP-1 RA within two to three weeks of first being offered this treatment, which makes this service very much patient centred.
This approach has demonstrated that pharmacists are more than capable of initiating GLP-1 RAs within a primary care setting and can help patients achieve their HbA1c and weight targets by providing the appropriate treatment and advice, therefore improving patient outcomes.
The work described here received a commendation award for the Patient Care Pathway, Secondary and Community category at the 2022 Quality in Care Diabetes awards.
The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.
Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.