Collaborative drug therapy management for initiating and adjusting insulin therapy in patients with type 2 diabetes mellitus.

Collaborative drug therapy management (CDTM) by pharmacists for initiating and adjusting insulin therapy in patients with type 2 diabetes mellitus in a Veterans Affairs Health Care System (VAHCS) is described. During 2003-04, the Veterans Affairs Maryland Health Care System (VAMHCS) at Baltimore reported that 24% of its patients with diabetes had a glycosylated hemoglobin (HbA(1c)) value of >9% or no recently documented HbA(1c) and that 91% of its patients with an HbA(1c) value of >9% were treated with oral antihyperglycemic agents alone. To address this issue, clinical pharmacists at VAMHCS at Baltimore developed the insulin initiation clinic. The primary goal of VAMHCS at Baltimore insulin initiation clinic was to provide an appropriate infrastructure to address the needs of patients with poorly controlled type 2 diabetes who required insulin therapy. Patients could be referred to the clinic if they had an HbA(1c) value of >9% on two occasions at least three months apart and were taking two oral antidiabetic medications whose dose was at least 50% of the maximal dose. The participating pharmacists mutually agreed to follow an insulin dosing protocol to help guide their therapeutic decision-making. Patients received comprehensive education during the initial visit regarding self-management skills, self-monitoring of blood glucose levels, treatment of hypoglycemia, insulin injection administration, and lifestyle modifications. Patients were discharged to their primary care provider if they attained an HbA(1c) value of <7.5% or after six months, whichever came first, during January 2005 and July 2008. Use of a preplanned insulin initiation and titration protocol by pharmacists resulted in the successful implementation of an insulin initiation clinic through CDTM and improved patients' glycemic control.