Patient Education for Diabetic Retinopathy Prevents Blindness—The Role of Compounding Pharmacists
Have you ever wondered what you can do to help patients prevent diabetic retinopathy? You’re not directly involved in first-line treatment—intravitreal injections—so you may think you don’t have much of a role, but that’s not true. Compounding pharmacists are in the best position to counsel patients who fill prescriptions to manage diabetes, which is an opportunity to remind them about eye screening. This is possibly the most important role of all because annual screenings lead to early treatment that offers hope for preventing or reversing retinopathy. Simply put, providing patient education for diabetic retinopathy can help prevent blindness.
Stages of Diabetic Retinopathy
Several theories exist to explain how diabetic retinopathy develops. One suggests that excess glucose is converted into sorbitol, which, in high levels, can weaken capillaries and cause microaneurysms—the earliest clinical sign of diabetic retinopathy. Edema develops as damaged capillaries leak serum, lipids and blood cells into the retina. Macular edema is the leading cause of impaired vision in people with diabetes. Another theory proposes that macular edema develops when increased levels of diacylglycerol activate protein kinase C, which affects permeability of the capillaries and leads to fluid leakage. Whatever the cause, diabetic retinopathy progresses through two stages:1
Nonproliferative diabetic retinopathy:
- Mild nonproliferative diabetic retinopathy (NPDR) – Patient has at least one microaneurysm.
- Moderate NPDR – Presence of hemorrhages, microaneurysms and hard exudates.
- Severe NPDR – Hemorrhages and microaneurysms are visible in four quadrants, with venous beading in at least two quadrants and intraretinal microvascular abnormalities in at least one quadrant.
Proliferative diabetic retinopathy:
- Significant neovascularization, most often near the optic disc or major retinal vessels.
- New blood vessels are more likely to leak and bleed, subsequently causing scar tissue, which causes retinal detachment.
Symptoms and Treatments for Diabetic Retinopathy
People with diabetic retinopathy usually don’t have any symptoms until the condition progresses to an advanced stage, when they begin to notice:
- Blurred vision
- Shadows or missing areas of vision
Managing blood glucose and maintaining HbA1c levels in the range of 6 to 7 percent can prevent or stop the progression of diabetic retinopathy. If retinopathy develops, early treatment reduces the risk of blindness by 95 percent.2 But people with diabetic retinopathy haven’t always had such a positive prognosis because the top treatments today—intravitreal injection of vascular endothelial growth factor (VEGF) inhibitors—have only been used to treat diabetic eye disease since 2014.
- Aflibercept – FDA-approved to treat diabetic macular edema in July 2014.
- Ranibizumab – Approved to treat diabetic macular edema in August 2012 and diabetic retinopathy in February 2015.
- Bevacizumab – Used off-label for diabetic macular edema; it’s only approved for ovarian, cervical and kidney cancers.
The PROTOCOL-T trial results, which were published in Ophthalmology in June 2016, found that all three drugs were equally effective, but the patient’s vision at baseline might guide medication choices.3 Patients with significantly impaired vision at baseline—20/50 or worse—had better results with aflibercept compared to bevacizumab. Aflibercept had similar results as ranibizumab—both help reverse vision loss—but patients had more rapid improvement with aflibercept. However, future studies need to explore the unexpected strokes and heart attacks that occurred in 5 percent of patients receiving aflibercept, 8 percent of participants getting bevacizumab, and 12 percent on those injected with ranibizumab.
Other treatment options for diabetic retinopathy and macular edema include:
- Laser photocoagulation – Individual microaneurysms may be treated directly or a grid pattern of laser burns can be used to treat nonspecific leakage. Laser therapy may be done in combination with VEGF or corticosteroid treatments.
- Dexamethasone and fluocinolone acetonide – These corticosteroids can be injected or implanted to treat diabetic macular edema.
- Intravitreal triamcinolone – Reduction in macular edema was reported in a clinical trial, but laser treatment is more effective.
- Ovine hyaluronidase – Phase III clinical trials using intravitreal injections of ovine hyaluronidase have achieved moderate success in subjects with proliferative diabetic retinopathy.
Screening Recommendations and the Roles of Pharmacists
The American Academy of Ophthalmology and the American Diabetes Association recommend the following screening guidelines:
- Type 1 diabetes – Eye screening within five years of diagnosis.
- Type 2 diabetes – Baseline eye screening at the time of diagnosis.
- All patients – Annual eye screenings going forward.
Just one yearly eye exam can catch the signs of retinopathy early enough to prevent blindness, yet only half of all diabetic patients get an annual screening. Physicians have conducted studies and the American Journal of Managed Care convened an expert panel to find ways to encourage patient compliance, but they didn’t come up with any answers. Here are a few of the roadblocks and how compounding pharmacists can help:
- Lack of physician intervention – One study found that 75 to 80 percent of endocrinologists always asked about eye-related concerns, but only 15 to 20 percent of internists discussed eye exams, even with patients who have diabetes.4 If patients can’t count on their doctors, then it’s more critical for pharmacists to come up with a simple reminder system for their diabetic patients.
- Gradual disease development – Within 20 years after the initial diagnosis, nearly all patients with type 1 diabetes and more than 60 percent of those with type 2 diabetes develop retinopathy. That’s a long time to go without symptoms, so patients aren’t motivated to pay for an eye exam. Many of them take medications to manage blood sugar, so you can remind them about the risk of retinopathy during medication reviews.
- Team collaboration – Diabetes requires a multidisciplinary team, which should include a pharmacist. You may not be involved with VEGF injections, but you definitely see these patients for a variety of pharmaceutical needs, from filling prescriptions to recommending transdermal options for healing diabetic foot wounds and formulating topical medications to relieve diabetic neuropathy. Reach out to other health care providers to be sure your expertise is added to the team. Studies show that when pharmacists are actively involved, diabetic patients improve compliance.
- Treatment costs – Medicare covers VEGF inhibitors, but that’s not true for all insurance carriers.5 Private insurance plans often require a deductible of $1,000 or higher, so patients delay care rather than paying out of pocket. Pharmacists can help patients navigate insurance challenges and apply for assistance from pharmaceutical companies.
Pharmacist Intervention From Counseling to Community Activity
There aren’t any easy answers for motivating patients to comply with eye screening or diabetic treatment recommendations, but one thing is sure—you have to start by making a connection. Compounding pharmacists have the advantage of accessibility. You can use medication management or go big and spearhead a community awareness campaign using resources provided by the National Eye Health Education Program.6 No matter what role you take, your efforts can help someone prevent vision loss from diabetic retinopathy.
Pharmaceutica North America provides a variety of high-quality bulk active pharmaceutical ingredients, custom compounding kits, unique delivery systems and OTC products that meet the needs of your patients with diabetes. Contact us today to talk about our pharmaceuticals and how we help support your compounding pharmacy.
- “Diabetic Retinopathy,” April 2015, http://emedicine.medscape.com/article/1225122-overview ↩
- “Facts About Diabetic Eye Disease,” September 2015, https://nei.nih.gov/health/diabetic/retinopathy ↩
- “Aflibercept Best in Diabetics With Bad Baseline Vision?” March 2016, http://www.medscape.com/viewarticle/859616 ↩
- “Reaching Patients Who Should Be Screened, Treated for Diabetic Macular Edema,” May 2016,http://www.ajmc.com/journals/evidence-based-diabetes-management/2016/May-2016/Reaching-patients-who-should-be-screened-treated-for-diabetic-macular-edema ↩
- “VEGF Inhibitors for AMD and Diabetic Macular Edema,” March 2015, http://secure.medicalletter.org/w1464b ↩
- “Diabetic Eye Disease: Resources,” 2016, https://nei.nih.gov/nehep/programs/diabeticeyedisease/resources ↩