A Three Minute Diabetes Consult: CKD
The Problem
According to a study in the September 2021 issue of Diabetes Care, an analysis of over 500,000 patients, across multiple health care organizations, found guideline-recommended testing for Chronic Kidney Disease (CKD) in people with diabetes is not being consistently done. The two recommended tests are estimated glomerular filtration rate (eGFR), and urinary albumin to creatinine ratio (uACR). The study authors conclude that while eGFR testing rates are high, the uACR testing rates are suboptimal and highly variable within the organizations examined.
Why is this important?
CKD or Diabetic Kidney Disease (DKD) occurs in about one-third of people with type 2 diabetes and many of them are unaware of the condition. If left untreated, CKD can lead to progressive loss of kidney function, ultimately resulting in dialysis or kidney transplant. The average life expectancy of a person undergoing dialysis is 5 years.
Kidney damage in people with diabetes is associated with microvascular damage caused by elevated glucose levels and is complicated by the addition of hypertension. The American Diabetes Association guidelines recommend controlling blood glucose and blood pressure to prevent onset and/or worsening of kidney function. The addition of pharmacological agents, shown to have positive cardio-renal effects, is also recommended
Recommendations for eGFR and uACR:
- At least annually beginning 5 years after diagnosis with type 1, and at diagnosis with type 2 diabetes.
- Every six months or more often if eGFR is 30-60 ml/min/1.73 m2 and/or uACR greater than 300 mg/g.
Your three minute “save a kidney” encounter for people with diabetes
- Ask your diabetes patients what their doctor has told them about kidney health.
- Have some copies a kidney disease handout ready to give to all patients with diabetes.
- Encourage patients to insist on both recommended tests yearly, or more often if indicated.
- If they have been diagnosed with CKD, suggest that they “know their numbers” i.e., CKD stage and uACR value.
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James Bennett BsPharm, CDCES, BCGP
Pharmacist Consultant,
MT DPH Cardiovascular and Diabetes Programs
Bozeman MT
Reference: Chronic Kidney Disease Testing Among Primary Care Patients With Type 2 Diabetes Across 24 US Healthcare Organizations, Diabetes Care 2021:44:2000-2009, Stempniewicz et al
Going Green: Reducing Inhaler Carbon Footprint
In a world where climate change is at the forefront of many discussions and decisions, patients and medical professionals are thinking about their medication use. Asthma treatment and inhaler use is one of the topics garnering a considerable review because inhalers may play a role in the carbon footprint. Metered dose inhalers (MDIs) and HFA inhaler propellants are potent greenhouse gasses and are 1000-3000 times more potent than carbon dioxide.
Ways to reduce the carbon footprint from inhaler use:
Optimize medication types and dosages. Over/improper use of inhalers leads to a greater number of inhalers required and, therefore, the amount of plastic thrown away. It also puts excess propellant into the atmosphere.
- One way that pharmacists can help is recommend that patients use their SABA inhalers only as needed. If they are needed more than two times per week, talk to their prescriber about optimizing their treatment plan. A second way that pharmacists can help is to teach them how to use their inhalers properly or to use a spacer to ensure full inhalation of medication.
Use dry powder or soft mist inhalers when appropriate.
- Ensuring proper treatment over global outcomes is key here. This option may not be appropriate for patients without the inspiratory flow required to use these inhalers or those prone to exacerbations.
When MDIs are prescribed, choose brands and a regimen that minimize carbon footprints
- Choose the inhaler with smallest waste footprint. Including the least amount of packaging used, less total plastic, or recyclable plastic
- Use inhaled corticosteroids at higher dosing to minimize quantity of inhalations
- For example, Qvar 200mcg 1 puff twice a day instead of Qvar 100mcg 2 puffs twice a day
- This can effectively cut the carbon footprint in half for one person’s treatment
Tell patients about the proper way to dispose of inhalers
- The Food and Drug Administration (FDA) recommends that patients read "handling instructions on the labeling of inhalers and aerosol products." Plastic pieces should be separated from metal parts when applicable and recycled separately.
- If medication is discontinued or expires before being used completely, the patient should be advised to not spray them out into the air. Patients should also be informed about returning them to the pharmacy through return programs to be disposed of in a proper manner.
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Check out this link to see where other inhalers rank of terms of their overall carbon footprint.
Written by: Logan Lesher, Pharm D Candidate with oversight by Rachael Zins, PharmD, AE-C
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