A Review on the Need of Advanced Clinical Pharmacy Education Services for Diabetes Prevention and Management in India in comparison with International Standards


A. Porselvi*

School of Pharmacy, Sathyabama Institute of Science and Technology, Chennai – 600119, India.

*Corresponding Author E-mail: arumugamporselvi@gmail.com



Clinical pharmacy is a health care discipline which focuses on clinical pharmacist’s involved patient care programmes to provide rationality in drugs use, to improve health and prevention and management of diseases. Clinical pharmacist directly can communicate with health care professionals and can resolve various health care issues related to patients. Clinical pharmacy services in the hospitals includes detecting of drug interactions, adverse drug events monitoring and filing, effective patient counselling, patient education, providing drug information services, monitoring of drug therapy, creating disease prevention and management awareness in the clinical setup. Diabetes mellitus is a chronic metabolic disease associated with elevated blood sugar levels which ultimate causes damage of vital organs of the human body. In western countries the practice of clinical pharmacy and education services for non-communicable diseases are well established effectively. In India, clinical pharmacy services are still to be flourished with advancement in delivering of high standard pharmaceutical care and effective clinical services in all the tertiary care hospital settings. This review mainly aimed to highlight the western practices of advanced clinical pharmacy services and to bring into limelight the same in Indian, the clinical pharmacy practice for a better health outcome for the future.


KEYWORDS: Clinical Pharmacist, Diabetes mellitus, advanced clinical pharmacy services, diabetes education.




Diabetes is a chronic metabolic disorders, it develops due to imbalance in insulin production or resistance for utilization in the body. The higher levels of glucose in the blood can damage vital organs in the body. The WHO also estimates around 80 percent of deaths due to diabetes occur in low and middle income countries. It was estimated that the global burden of diabetes mellitus rise to 438 million by 20301. In India, diabetes is one of the major chronic diseases and the rural populations are the most affected. Diabetes screening, identification and management of co-morbid conditions at early stage are a must to reduce the prevalence of diabetes complications.2,3


Diabetes burden in India:

Currently, India has 62 million populated diagnosed with diabetes. In 2000 India had topped the world’s highest diabetes mellitus patients. People with diabetes require at least 2-3 times the health care resources than who do not have diabetes. Diabetes care accounts for up to 15% of national healthcare budgets4-6. The etiology of diabetes in India is multifactorial and includes genetic factors coupled with life style influences such as obesity associated with rising living standards, urban migration, and food style modifications. Illiteracy, poor sanitation and dominance of communicable diseases may also contribute directly or indirectly to diabetes. It could be render to both the policy makers and local governments should initiate warning alert to prioritise the looming threat on diabetes.


Diabetes and its co-morbid complications:

A study on International status of diabetes reported that the diabetes control worsened with longer diabetes duration neuropathy as the most common complication (24.6 per cent) followed by cardiovascular complications (23.6 per cent), renal issues (21.1 per cent), retinopathy (16.6 per cent) and diabetic foot ulcers (5.5 per cent). These results were similar with other results from the studies of South Indian population, however further more data from different states of India are required to confirm whether patterns of complications vary across the country7,8. A study compared waist-to-weight ratio (WHtR) with traditional anthropometric indices in healthy women aged 21 to 45 years from urban slums of Mumbai city, India found mean value of WHtR 0.50± 0.1, but a little more than half (51.9%) of the women had WHtR ≥0.50. Poor glycaemia control is a main factor that is responsible for micro and macro vascular changes in the Indian diabetic population and can predispose diabetic patients to other complications such as diabetic necrosis and muscle infarction.


Indians are genetically predisposed to the development of coronary artery disease due to dyslipidaemia and low levels of high-density lipoproteins. These determinants makes Indians more prone to development of diabetes at an early age of 20-40 years as compared to Caucasians which indicate that diabetes must be carefully screened and monitored regardless of patient age in India9,10.


Challenges in the management of Diabetes in India:

There are number of challenges that plague diabetes care in India. While HbA1c is the gold standard test around the world for insulin initiation and intensification, it is not easily available to a large section of Indian population. There is a clinical apathy for the commencement of insulin therapy in both the clinical and patient communities. The most common apprehensions are related to the complexities of the insulin regimen and concerns about weight gain, hypoglycaemic events and fear of insulin prick. Lack of adequacy in Indian guidelines is also responsible for wide variation in treatment preferences across the country. The creation of simple and practical insulin guidelines can be incorporated into routine clinical practice to facilitate treatment and the initiation of insulin therapy throughout the country11.


International scenario of Diabetes mellitus:

The United States of America developed a number of public and private funded programmes to prevent and manage diabetes that had proved to be successful. Similarly, the Australian government runs programmes called “National Health Priority Areas initiative” to provide focussed and continuum of care and attention on chronic disease like diabetes. The United Kingdom government places special emphasis on diabetes care in patients, with the National Health Service conducting various patient education programs and trials to improve quality of life of patients. The United Arab Emirates has set up an expert panel to form guidelines for diabetes management and public awareness programmes. This has resulted in positive health effects which may arrest rising trend in diabetes cases in that country. In India, similar efforts and services are required at ‘grass roots’ level to contain the new-age diabetes pandemic. Many health systems are now adding clinical pharmacists to meet these standards and these numbers supposed to increase rapidly in the next several years.


Diabetes care should be a person-centered and it should aim to empower individuals to manage their own diabetes conditions. A study form Philippines described the situations of a diabetes patient and identified possible barriers to diabetes care and medications. They concluded with Insurance out-patient coverage and application of standard treatment/management guidelines that would help to encourage for providing and receiving regular care. Professionals providing diabetes care should support individuals to manage their own diabetes and help them to adopt and maintain a healthy lifestyle12. They should actively encourage partnership in decision-making and enabling people with diabetes to have choice, voice and control over what happens to them at each step of their care. A care plan, negotiated and agreed with each individual in an appropriate format and language preferred by the individual and reviewed as part of the care planning process.


The responsibilities of the diabetes patient include:

·       Take as much control of their diabetes on a day-to-day basis as possible

·       The diabetic patient must know about self-care, which includes dietary management, exercise, the monitoring of blood glucose levels

·       To examine the feet regularly

·       To know how to manage their diabetes

·       To build into their daily life a regular discussion with the health care team

·       To clear questions on health issues during consultations

·       Attend the scheduled appointments and inform the healthcare team if they are unable to attend within the schedule

·       A special care to be provided for the  patients like,

Ø Children and young people with diabetes

Ø Women with diabetes who are considering pregnancy or who are already pregnant.

Ø Any person with diabetes the specialist advice is required regarding the management of metabolic control, cardiovascular risk factors or diabetic complications.

Ø People with complex psychological problems.


Need for Implementation of Nationalized Awareness Programme (NAP):

Indian guidelines should be improved adequately with due responsible for wide variation in treatment preferences across the country. Creation of simple and practical insulin guidelines that can be incorporated into routine clinical practice by primary health care physicians are desperately required to facilitate treatment and the initiation of insulin therapy throughout the country13. To reduce the diabetes disease burden in India, appropriate support from public, health care practitioners and more awareness programmes by the government are required. Clinicians may be targeted to facilitate the awareness programmes and effective implementation of screening and early detection programmes relates to meet the diabetes preventions and self-management counselling and therapeutic management of diabetes14. Approaching the diabetes guidelines and its application in the clinical practice helps to controls the diabetes in epidemic. Early screening and detection of pre-diabetes especially in pregnant women, children and adults may impacts the positive health outcomes in society. Continuing education programmes for pharmacists can unveil the “clinical inertia” required to initiate programme adherence, and may be a major step in achieving diabetic control and help for prevention of disease complications. Education on aggressive clinical measures in terms of early insulin initiation combined with optimal doses of oral hypoglycaemic agents and appropriate lifestyle modification to the patients by pharmacists could also have a long-term positive effect in disease management15-16. Currently existing diabetes mellitus management programmes are listed in figure1.


Fig 1: Diabetes mellitus management program


Role of health care personnel to support and encourage diabetes self-care and self-management14

Ø Treating individuals with respect and dignity.

Ø Ensure that patients with diabetes know how to contact members of the team providing their diabetes care.

Ø Provide high quality care and regularly review their clinical and psychological needs.

Ø Answer any questions about the quality of services received.

Ø Provide interpreting services, if English is not the person’s first language and seek appropriate services for those with sensory impairment or learning disability60-62.

Ø Provide information and structured education about diabetes management and local health related services.

Ø Remain up to date about diabetes and its care and treatment in order to keep patient with diabetes up to date about their condition.

Ø Facilitate access to a second opinion where required (subject to the agreement of the person’s GP or consultant).

Ø Give information about local government services if any and details of local support groups.


Clinical Pharmacy Services:

The pharmacist role in health care system is a continuous patient care services ensuring the rational use of medications. The development of clinical pharmacy services helps to establish new treatment, screening programmes, patient education and follow-up counselling particularly for life style diseases. They can provide recommendation of evidence-based medication selection and offer drug information services to the health care providers and to the patients17,18. However, the expected out comes depends on the proper use of treatment guidelines and reach-out of health care suggestions beneficial to the patient community. The clinical pharmacist should meet with the relevant legal, ethical, social, cultural, economic and professional principles during their clinical practice. Clinical pharmacist requires the continuous training programmes in the clinical pharmacy practice areas and should have the widest knowledge on Pharmacokinetics, Pharmacodynamics, Pharmaco-therapeutics, clinical toxicology and pharmacology arena.


Clinical Pharmacy Services in diabetes management:

The clinical pharmacist may meet more challenges during his/her practice and most of the time they work in collaboration with multiple health care team in hospitals. Hence, every pharmacy practitioner requires proper training and good academic background on clinical pharmacy education and services. The evidence based clinical pharmacy practice requires continuous learning and training in various aspects of patient care. The clinical pharmacist should possess a basic qualification of Pharm.D, or post graduate in clinical pharmacy or in hospital pharmacy with adequate training in clinical pharmacy servicing to act as a preceptor in clinical pharmacy19.


Table 1: Type of services and its purposes22-26

Name of the Department

Type of Clinical care

Clinical Pharmacy services

Teaching Hospitals attached research institutes

Hospital pharmacy practice, teaching activities, drug selection, distribution, management.

Making effective changes in education, training, teaching programmes in medical and health sciences.

Emergency Medicine

Drug therapy monitoring and drug information services

Determine types of critical conditions of the patient, solving the drug related problems, providing evidence based information to the physicians27.

Community pharmacies73

Conducting health screening, awareness programmes, training programmes.

Educational and training opportunities for community pharmacists, thereby improve patient-centred knowledge providing advanced pharmacy services28.

In-patient department

providing Pharmaceutical care services

Provision of pharmaceutical care, identification of drug therapy problems, prevention of adverse drug reactions and monitoring of drug therapy management80.

Out-patient department

Ambulatory care29-30, patient education

Advancing ambulatory care practice, to achieve the national priorities of improving patient care, adherence, patient health, and affordability of care.

General medicine

Identification of various diagnosis cases

Providing counselling to the chronic, non-communicable cases.

General surgery

Identification antibiotics prescribing pattern in operative cases

Providing drug related information to the physician, antibiotic alternatives.


Identification of   chronic inflammatory lung diseases associated co morbidities.

Providing counselling to the pulmonary disease associated co morbidities patients towards prevention and management.

Obstetrics& Gynaecology

Identification of gynaecological cases

Assessing drug use pattern in a post-operative patients, Providing treatment alternatives to the health care professionals31-35.


Identification of psychiatry related disorders

Providing patient counselling, drug related services to the patients.


Identification of bone related disorders

Providing antibiotic information, lifestyle interventions to the patients.

Paediatric department

Identification and evaluation of  multiple diseases81

Provision of advanced paediatric care services.

Intensive care units and oncology department

Palliative care services64,82-83

Introducing the concept of advanced practice roles in pharmacy within the new integrated regionalized palliative care service36-40.


The advanced clinical pharmacy services can be implemented in facilities like teaching hospitals attached in research institutes, community pharmacies and in various departments. Some of those facilities and their services are listed in Table1.The challenges on managing the chronic conditions of the patients to provide health care management which was previously termed as disease-state management.


Western University health systems include education to support basic medication management services on a consistent basis. Internationally several educational institutions focussing on better clinical services to reach the community and offers a specialized care for the patients on the various clinical situations. In India, apart from University curriculum there are no any special medication management trainings under use. In some Indian educational institutions there are some important software installed which are being utilized by the students free of cost.


A rapid development of technology in health care like drug information provider software Micromedex, Drug interaction checker Software, Medline, Medscape, E-medicine, Webmed etc. are required to update the various diseases and drug information which can be provided to the patients at appropriate level that can meet the health care demands. Advanced clinical pharmacy interventions are focused on medication reconciliation during the admission and discharge of the patients.


The diabetic patients are provided with continuous patient tailored education supported by periodic counselling20. The intervention was started to the patients by selecting them on the basis of diabetes severity and treatments patterns are designed accordingly during their hospital stay.  The medications prescribed to the patient include antibiotics, pain killers, antithrombotic or anti-arrhythmic drugs and chemotherapeutic agents21. Clinical pharmacist deals on medication therapy management, patient counselling, disease prevention and management and follow up of patients etc.


According to National service frame work for Diabetes, UK structured patient education means, it is a planned course that:

Ø Covers all aspects of diabetes

Ø Flexible in content

Ø Relevant to a person’s clinical and psychological needs

Ø Adaptable to a person’s educational and cultural background

Advanced Clinical Pharmacy Services in the Community Practice   

An array of advanced clinical pharmacy services in the community practice is depicted in figure 2.


Identification of diabetic patients in the community


Health screening, identification of status of sugar levels


Renew the goals of diabetes mellitus prevention and management


Promoting patient counselling, patient education services


Life style interventions, monitoring the patients


Maintain the sugar levels at normal level, improving the health related outcomes


Fig 2: Advanced Clinical pharmacy service in diabetes


Structured Education Programmes (SEP) for diabetes patient41-46

There are two national patient education programmes in U.K that meet all the key criteria for structured education are

·       DAFNE for Type 1 diabetes mellitus

·       DESMOND for Type 2 diabetes mellitus



Dose Adjustment for Normal Eating (DAFNE) is skills based course in which people with type 1 diabetes learn how to adjust their insulin dose to suit what they eat, rather than having to eat to match their insulin dose.



Diabetes Education and Self-Management for On-going and Newly Diagnosed (DESMOND) is a new course for people with type 2 diabetes which helps to identify their own health risks and to set their own specific treatment goals.


Principles of good clinical practices in Structured Education Programme47-50:

The following figure 3 lists and explains the principles of good clinical practices in Structured Education Programme



Courses should reflect established methods of adult learning and the curriculum should be clearly written down


Courses should be run by appropriately trained professionals from a variety of backgrounds (such as nurses and dietitians) to groups of people with diabetes, unless group work is considered unsuitable for an individual


Sessions should be accessible to the broadest range of people, taking into account the person’s culture, ethnicity, and any disability they might have and where they live


Sessions should be held locally, for instance in a community setting or local diabetes centre 21


Courses should use a variety of teaching styles to promote active learning, where everyone gets involved and can relate what they are learning to their own experiences


Courses should be adapted to meet the different needs, personal choices and learning styles of people with diabetes


Education should become part of the normal diabetes care

Fig 3: Principles of Good clinical practices in Structured Education Programme


Benefits and scope of Structured Education Programme:

Diabetes affected children, young people and adults shall be given necessary services which can encourages partnership, decision-making supports them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle51-55.


Structured education is one of the key interventions needed to achieve the standard care. According to the National Institute for Clinical Excellence (NICE) recommends that structured patient education should be made available to all people with diabetes at the time of initial diagnosis and should then be available as required on an ongoing basis which includes:

1.     Prevention of Type 2 diabetes, practices should have systems in-place for identifying people at increased risk for developing diabetes so that they can be provided support by offering them appropriate advice on how to reduce the disease risks56-58.

2.     Identification and diagnosis of people with diabetes, people with diabetes remain undiagnosed and a high index of suspicion amongst all members of the primary healthcare team is therefore essential. In addition, practices should have systems in place to actively identify people with undiagnosed diabetes their priority should be to focus on those known to be at high risk of developing diabetes65-67.

3.     Initial assessment and care at the time of the diagnosis, once the diagnosis of diabetes had been confirmed. Patients should be assisted to get referral to diabetes specialized team and if needed treatment and care should be initiated. This should include the provisions of education about diabetes and its management, including the provision of dietary advice59-63.

4.     Initial and on-going education mechanisms for ensuring that all people with newly diagnosed diabetes receive initial and on-going education about diabetes and its management should be agreed. The provision of education should be based on adult learning principles that promote active learning which is ideally provided within a group format, unless considered inappropriate64

5.     Dietary advice by a registered dietician, general practitioners and community nurses on diabetes must be provided to all newly diagnosed patients68-71.

6.     Continuing care of once their diabetes has been stabilised, people with newly diagnosed diabetes should be invited to attend for regular reviews of their day-to-day metabolic control and on-going education, as frequently as required to meet the needs of the individual. In addition, they should be recalled at least once a year for a formal review of their metabolic control and the quality of their daily life, and should be offered annual surveillance for cardiovascular risk factors and long-term complications. Further follow-up appointments should be offered as appropriate to focus on any issues raised during annual reviews72-79.



Diabetes mellitus is reaching potentially epidemic proportions in India. The level of morbidity and mortality due to diabetes and its potential complications are enormous, and pose significant healthcare burdens on both families and society in the world84-86. Therefore, there is a demanded need to implement population-based interventions that prevent diabetes, enhance its early detection, lifestyle and pharmacological interventions to prevent the complications. In India, regular migration of people from rural to urban areas, the economic boom and corresponding change in life style are all affecting the status of diabetes. It is now highly developing across all sections of society within India, there is now the demand for immediate initiation of research and intervention programmes at regional and national levels to reduce the potentially catastrophic increase in diabetes that is predicted for the upcoming years.


Internationally clinical pharmacy services are well established but in India still these activities are at infant stage. The rapid change in pharmacy services is the need of hour and should upgrade the pharmacist activities to clinical pharmacist. It includes not only compounding and supplying drugs roles and also directly involving in the patient care. Advanced clinical pharmacy education and services should be done by clinical pharmacists at various facilities where standard pharmaceutical care is made available and preceptors and educators should be actively engaged with their clinical services87-89. Efforts to reduce the global health and economic burden of diabetes among the high-risk individuals should emphasise to delay the onset of the disease through enhancing healthy behaviours and diets. Identifying people at early risk stage of diabetes especially those with impaired glucose tolerance through the primary care system can be provided with proper medical advice and support to reduce the disease worsening in the community90-92. Early detection and management, lifestyle changes will be the short-term approach for diabetes prevention. Effective implementation of advanced clinical pharmacy services can helps to prevent the development of diabetes and its associated complications much in future93-95.



Author declares no conflicts of interest.



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Received on 14.12.2019           Modified on 19.02.2020

Accepted on 01.04.2020         © RJPT All right reserved

Research J. Pharm. and Tech. 2021; 14(1):493-500.

DOI: 10.5958/0974-360X.2021.00090.1