Patient safety is the priority of all healthcare workers. However, the treatment and management of co-morbid conditions has proven to be challenging even to the healthcare professionals. This is because the available clinical guidelines are mainly based on the assumption that patients suffer from a single disease (1). Diabetes co-existing with hypertension (HTN) is a very common occurrence especially in type 2 DM (Diabetes Mellitus) patients. According to The Global Burden of Disease study HTN and DM have been identified to be the leading cause of untimely deaths and disability globally (2).

It is globally estimated that the prevalence of type 2 diabetes mellitus (T2DM) will be 366 million by 2030 whereas that of hypertension will be 1.56 billion adults by 2025 (3, 4). The prevalence of hypertension in diabetic patients is almost double that of non-diabetic and the patients with hypertension as a comorbidity are at a higher risk of mortality and cardiovascular disease development (5, 6). A study by Geldsetzer et al (7) which involved 1.3 million adults in India revealed that this comorbid condition was more prevalent in the middle and old age. Having a team approach (i.e., physicians, nurses, clinical pharmacists, dieticians, etc.) in the therapy of DM with HTN patients has shown to be effective (8). Managing the blood pressure levels in diabetic patients, adherence to both pharmacological and non-pharmacological treatments such as exercising, etc., and use of proper medication with minimum adverse effects are some of the methods that can be used to reduce the risk of developing hypertension in diabetic patients.

Clinical pharmacists are specially trained personnel on pharmacotherapy and their major role in healthcare setting is to ensure safe, effective, and judicious use of medications in the patients (9). They identify drug related problems (DRPs) which are recurrent in hospitals particularly during prescribing, dispensing, administration and adherence of the drugs (10). A drug related problem is a negative outcome of a medication administered to a patient and fortunately, they are mainly preventable. Clinical pharmacists have been encouraged to use the SOAP (Subjective, objective, assessment, plan) or FARM (Findings, assessment of findings, resolution of the problems and monitoring) progress note in order to easily identify and report DRPs (11, 12). Common outcomes of DRPs in DM with HTN patients include: decreased quality of life, longer hospital stays, and increased costs (13).

The inclusion of clinical pharmacists in the healthcare team helps address the challenges related to DRPs as they offer valuable interventions on case-by-case basis. A randomized clinical trial study showed that the addition of clinical pharmacist to the healthcare team resulted in decreased mortality and healthcare costs. The pharmacist interventions were on the drug selection, dosages and monitoring needs during the study (14). Additionally, patient counselling and follow-up is another common pharmacist intervention. Clinical pharmacists have therefore become an integral part of quality healthcare delivery systems even as more emphasis is being laid on team care-based model (15, 16).

The absence of long-term published describing the clinical pharmacists’ interventions in India was the rationale for conducting this study. Therefore, the main objective of this study was to investigate the pharmacist interventions in minimizing drug-related problems in diabetes with co-existing hypertension in the medicine departments of three hospitals in Punjab, India.

Out of 1,914 patients, 914 were male (47.8%) and the females were 1,000 (53.65%).

During the study, 63 different types of ADRs were detected by the clinical pharmacist in 628 (32.8%) of the patients. The majority of the patients were suffering from adverse drug reactions like hypotension (3.3%), hypoglycaemia (3.2%), mild itching or rash (1.5%), swelling in their feet or ankles, severe drowsiness (1.4%) followed by skin rashes (1.0%). In 1,914 patients, 42 different kinds of drug interactions were observed in 1,612 cases. The majority of the drug interactions were seen between Insulin + Emeril 226 (11.8%) followed by 111 (5.8%) Emeril + PCM + Diclofenac. The drug-related problems include inappropriate drug form (6.1%), inappropriate drug (4.6%), no clear indication for drug use (4.6%), contraindication for the drug (4.1%), no drug prescribed but clear indication (3.8%), and duplication of a therapeutic group or active ingredient (1.5%).

Additionally, change in frequency of administration was found to be 153 (8.0%), addition of drug 89 (4.6%), change in the duration of therapy 50 (2.6%) and change in drug dose 33 (1.7%). Pharmaceutical aid was included in 22 (1.1%) of the cases.

Tables 1, 2 below demonstrates the characteristics of the drug prescriptions and types of drug related problems noted and their statistics (Tables 3, 4).

The mean number of generic drugs prescribed was found to be 3.15 whereas the maximum drugs was found to be five. The mean number of antibiotics prescribed was found to be 1.10 whereas the maximum number of antibiotics prescribed was found to be four. On evaluation of number of injections prescribed it was observed that the mean number of injections prescribed was found 2.17 whereas the maximum number of injections prescribed was found to be five in a day. The mean number of drugs prescribed from essential drug list (EDL) 2.33 whereas the maximum number of drugs prescribed from essential drug list was found five.

Embracing clinical pharmacy in treatment of patients has shown to be effective particularly in minimizing the economic burden and development of adverse drug reactions. Pharmacist interventions within a multi-disciplinary team have proven to be vital especially in conducting drug reviews. Drug review is a major component of pharmacy practice and it involves assessment of the medications given to patients and their possible outcomes (intended or unintended) (25, 26).

Inappropriate drug form and dose being too high were the main drug related problems discovered in our study. Another study by Rasool et al (27) showed a similar outcome with inappropriate drug from being responsible for 39.75% of the medication errors seen.

A trial conducted by Sosale et al showed that 46% of patients diagnosed with type 2 diabetes mellitus are under the age of 40 (mean age was 34.7 ± 4.2 years) whereas the mean age of our study population was 54 years (28). The reason for this discordance in the age may be due to the different aims of the studies. Their study was tailored towards determining the onset of T2DM in young patients whereas our study had no specific target age group. Drug interactions were seen in 84.2% of our patients which was a little higher than the 70% which was seen in a study conducted by Sankar et al (29). Interestingly, their study only involved 50 patients which may not be able to give a proper representation of the larger population and hence this small difference. A study by Zazuli et al showed that inappropriate drug selection and inappropriate dosage selection contributed 25.3% and 4.4%, respectively occurrence of drug related problems. In our study, inappropriate drug form and inappropriate drug given contributed 6.11% and 4.65%, respectively in the 1,914 cases. Additionally, substituting the drug was the main intervention given by clinical pharmacists as seen in Figure 2. In their study, drug choice problem and dosing choice problem contributed 88.2% towards drug related problems (DRPs) whereas it only contributed 49.2% in our study. This was due to the fact their study was a prospective study for 3 months. In our study, it was revealed that patient compliance status was the most significant factor influencing the DRPs (30).

Our study revealed that pharmacists play a major role especially in patient follow-up and that patient compliance is very critical in ensuring desired therapeutic outcome. Also, as seen from other studies proper counselling, patient education and creating public health awareness improves the patients’ compliance (31). Some studies have shown a very good compliance rate of DM with HTN patients such as one conducted by Rao et al where 83.6% of the diabetics were compliant to their medications (32). Poor compliance and non-compliance were discovered to be the most prevalent medication related problem in our patients as they contributed 47.3% and 26.3%, respectively. A recent study has called on the National Programme for Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) in India to conduct more health awareness programmes especially in Punjab where there is a high rate of NCDs (Non-Communicable Diseases) (33). Multidisciplinary collaboration among the healthcare workers such as nurses, pharmacists and physicians has also proven to be a better means of achieving better patient care (34). This study is the first of its kind in North India because the sample size used in this study can be used to give an insight into the factors that are responsible for drug related problems in DM with HTN patients. This study was a 5-year study hence the results have a better representation generally of the kind of interventions involving pharmacists within our region. Furthermore, our study reveals the need for a more collaborative approach in medication treatment with the clinical pharmacist expected to play a great role in patient education as well as counselling.