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Introduction

Treatment of patients with type 2 diabetes mellitus (T2DM) must be tailored to the needs of each long-term care (LTC) resident, beginning with developing individualized glycemic goals based on an assessment of clinical and functional status.¹ In most cases, the target range glycated hemoglobin A1C (HbA_1c)  will be higher for older LTC residents (eg, less than 8.5% or less than 8.0%) than those recommended for the general T2DM population (eg, less than 6.5% or less than 7.0%).² Keeping HbA_1c, fasting blood glucose (FBG), and post-prandial glucose levels within target ranges requires the collaboration of all members of the T2DM care team. Interdisciplinary teams that include pharmacists in the LTC setting are vital for providing safe and effective treatment outcomes.

Managing comorbidities present in patients with T2DM can be particularly challenging in the LTC setting. Older patients with T2DM have an increased prevalence of comorbid conditions such as cardiovascular disease, kidney failure, liver impairment, and cancer.³ Treating these commonly encountered comorbidities contributes to the high burden of polypharmacy among patients with T2DM. Moreover, many of these comorbidities themselves represent potential contraindications to T2DM medications.³ Even with evidence-based T2DM treatment regimens, the risk of hypoglycemia may remain elevated in LTC residents due to variable appetite and nutritional intake, suboptimal hydration, slowed intestinal absorption, and declining health status.^1-2 Therefore, minimizing the risk and occurrence of hypoglycemia in patients with T2DM in LTC must always be a priority.¹

Consultant pharmacists involved in the management of patients with T2DM have an array of drug classes at hand, including oral antidiabetes drugs, injectable noninsulin therapies, and insulin. Due to the progressive nature of diabetes, most patients with T2DM will eventually require insulin therapy to achieve and maintain glycemic goals.² However, insulin products are frequently involved in medication errors with potentially harmful errors reported at each step of the medication-use process (ie, prescribing, transcribing, dispensing, storage, administering, and monitoring).⁴ Current guidelines recommend simplified insulin regimens for older patients with T2DM, with a focus on avoiding sliding-scale insulin (SSI) due to an increased risk of hypoglycemia and less success in achieving treatment goals.^2,5 Consultant pharmacists play a vital role in the safe and effective use of insulin therapy, particularly in the LTC setting. Maintaining awareness of the contraindications of various therapies, preventing medication errors, and matching the right treatment regimen to each patient remains a challenge. When pharmacists play a collaborative role in reviewing medications and educating other healthcare professionals in the LTC setting about medication safety, pharmacotherapy for older patients is improved.⁶