1. Pharmacists’ Role in Diabetes Care © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044

2. You are a Critical Member of the Diabetes Care Team In 2003 the American Diabetes Association formally included pharmacists as integral members of diabetes care teams. The role of pharmacists as health care provider has been long recognized. Over a 12-year period (1982-1994), the percentage of patients receiving written communications about prescription medications rose from 16% to 59%. 1 A multidisciplinary consortium concluded that pharmacists are a dramatically underused resource that could help improve outcomes and lower costs. 2 Diabetes Care and Pharmacotherapy report increased involvement by pharmacists in direct care of patients with diabetes. 3.4 Patients who received additional care from pharmacists saw significant improvement in A1C, blood pressure, and LDL cholesterol levels. 5 2 1.Morris LA, et al. Medical Care. 1997. 2.American Pharmacists Association Foundation and American Pharmacists Association. J Am Pharm Assoc. 2013;53:e132-e141. 3. Santschi V, et al. Diabetes Care. 2012; 35:2706–2717. 4. Wubben DP, Vivian EM. Pharmacotherapy. 2008; 28:421–436. 5. Rothman RL, et al. Am J Med 2005; 118:276–284.

3. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 Your Role in Patient Care Gaps between health care provider visits and time pressures during visits can result in patient confusion and compromised adherence. Pharmacists make significant clinical contributions with: Patient education and counseling MTM/preventing medication errors Improving adherence to monitoring and medication Health barriers assessment Identifying people at risk for diabetes Advice on condition, including lifestyle changes 3

4. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 Research Indicates 1 4 A systematic review and meta-analyses demonstrate the benefit of including the pharmacist in direct patient care. Favorable therapeutic and safety outcomes Significant effect on A1C, LDL cholesterol, blood pressure, and adverse drug events Quality-of-life and general health improvements 1.Chisholm-Burns, MA. Medical Care. 2010; 48(10).

5. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 5 The Impact of Diabetes Conditions and Complications Among People Diagnosed * Includes diagnosed and undiagnosed people with diabetes. Source: CDC. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Hypoglycemia CrisesHyperglycemia Crises 282,000 ER cases of adults 175,000 ER visits High Blood PressureHigh LDL Cholesterol 71% ≥140/90 65% had blood LDL cholesterol ≥100 mg/dL Blindness and Eye Problems 4.2 million (28.5%) adults ≥40 years had diabetic retinopathy 655,000 (4.4%adults ≥40 years were diagnosed with severe vision loss Kidney Disease 49,677 people of all ages began treatment for kidney failure due to diabetes US Population with Diabetes = 29.1 million or 9.3%*

6. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 Your Role Is Important As a valuable member of the diabetes care team, you can enhance patient care and health outcomes. Ascertain whether your patients know and understand their A1C goals Encourage your patients to better manage their diabetes Understand the health complications associated with diabetes 6

7. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 7 Pharmacists are on the front line of one of the most costly aspects of health care—preventable medication errors. A recent study showed how therapy assessment and reconciliation by pharmacists can result in significant overall health care cost savings. 1 Decreased readmission rates at 7 days: 0.8% vs 4%; 14 days: 5% vs 9%; and 30 days 12% vs 14% $35,000 savings per 100 patients, translating to more than $1.5 million savings annually 80% of patients had at least one medication discrepancy upon discharge Your Role Is Important (cont’d) 1. Kilcup, M, et al. J Am Pharm Assoc. 2013;53(1):78-84.

8. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 8 Your Role Is Important (cont’d) How a medication is working for a patient will be top of mind when ordering and picking up refills. This is a good time to check in with your patients and ask them a few questions such as: What was your last A1C level? What’s your typical morning/fasting blood sugar range? How often do you experience low blood sugar and how do you treat it? Are you confident that your blood glucose monitor is working correctly?

9. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 9 Facts for Your Patients

10. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 10 Types of Diabetes Type 1 diabetes – The body no longer produces insulin, so the sugar cannot move into the cells to become energy Type 2 diabetes – The body either doesn’t produce enough insulin or use it well enough to move sugar from the blood into muscles and cells for energy With both types of diabetes, blood glucose builds up in the body and can lead to: - Neuropathy (nerve damage and pain) - Nephropathy (kidney disease) - Retinopathy (eye disease that can lead to blindness) - Premature death

11. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 Lifestyle Management – Diet Discuss with your patients what they like or don’t like to eat Ask your patients how they quench their thirst. Many don’t realize how sugary drinks impact blood glucose levels. “Create Your Plate” may help patients eat a variety of nutritious foods and understand portion sizes at each meal. 11

12. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 Lifestyle Management – Exercise Discuss the importance of exercise with your patients Potential benefits of exercise 1-3 1. American Diabetes Association. Physical activity is important. www.diabetes.org/food-and-fitness/fitness/physical-activity-is-important.html. Accessed July 1, 2014.www.diabetes.org/food-and-fitness/fitness/physical-activity-is-important.html 2. American Diabetes Association. What we recommend. www.diabetes.org/food-and-fitness/fitness/types-of-activity/what-we-recommend.html. Accessed July 1, 2014.www.diabetes.org/food-and-fitness/fitness/types-of-activity/what-we-recommend.html 3. American Diabetes Association. Stretching and balance exercises. http://www.diabetes.org/food-and-fitness/fitness/types-of-activity/stretching-and-balance-exercises.html. Accessed July 1, 2014..http://www.diabetes.org/food-and-fitness/fitness/types-of-activity/stretching-and-balance-exercises.html –Improves circulation – Assists weight control –Develops strength, balance, and flexibility Discuss with your patients that they should check with their health care provider before starting any new exercise programs 12 Ask if they do any of these –Walking –Strength or resistance activities –Swimming –Lifting light weights – Controls blood sugar –Taking the stairs or step exercises –Stretching –Flexibility exercises

13. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 Be Aware of Hypoglycemia (Low Blood Sugar) Low blood sugar occurs when a patient’s blood sugar level drops too low to provide enough energy for the body’s activities Low blood sugar is most often caused by 1 : –Excessive doses of insulin or some diabetes medications –Meals or snacks that are too small, delayed, or skipped –Increased activity or exercise –Excessive drinking of alcohol Hypoglycemia can occur without symptoms and can be difficult to recognize in patients. Encourage patients to regularly check blood sugar levels. 13 1. National Diabetes Information Clearinghouse. Hypoglycemia. http://www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia. Accessed July 3, 2014.http://www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia.

14. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 Symptoms of Hypoglycemia 1 14 Hunger Nervousness Dizziness Shakiness Drowsiness Feeling anxious Weakness Confusion Sweating What to Do for Hypoglycemia—The Rule of 15 2 You may be able to help your patients avoid an ER visit by talking to them about the Rule of 15. At the first sign of hypoglycemia: Eat or drink 15 grams of a fast-acting carbohydrate (5-6 hard candies, 3- 4 glucose tablets, ½ cup juice, or ½ cup regular soda). Wait 15 minutes and test again. If your blood glucose is not returning to normal, eat or drink another 15 grams and test again. Resume normal meals after your blood glucose stabilizes. 1.National Diabetes Information Clearinghouse. Hypoglycemia. http://www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia. Accessed July 3, 2014.http://www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia 2.American Diabetes Association. http://www.diabetesforecast.org/2014/Jan/glucose-products-2014.html. Accessed July 29, 2014.http://www.diabetesforecast.org/2014/Jan/glucose-products-2014.html

15. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 Be Aware of Hyperglycemia (High Blood Sugar) 15 High blood sugar occurs when a patient’s body has too little insulin or when the body can’t use insulin properly. 1 Causes 1 : –Type 1 – patient may not have received enough insulin –Type 2 – patient may not have an adequate level of medication –Improper dosing of prescribed medication –Too much food –Too little exercise –Stress of an illness, such as a cold or flu 1.American Diabetes Association. Hyperglycemia. http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hyperglycemia.html. Accessed July 3, 2014.http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hyperglycemia.html

16. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 Have Your Patients Protect Their Skin 1 Remind patients to keep their skin clean and dry Use moisturizing soaps when bathing Moisturize skin to prevent chapping, especially in cold or windy weather Treat cuts, burns, or infections right away 16 1.American Diabetes Association. Skin Care. http://www.diabetes.org/living-with-diabetes/complications/skin-care.html. Accessed July 3, 2014.http://www.diabetes.org/living-with-diabetes/complications/skin-care.html

17. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 17 Help Protect Your Patients’ Feet 1 Ask your patients specific questions about their feet 2 -Do you have burning or tingling sensation in your feet? -Do you have cold feet? -Do you have bunions, corns, or calluses on your feet? -Do you have chronic scaling, itching, or dry feet? -Do you have any sores on your feet or infections that won’t heal? Remind them to -Rub lotion over their feet and toes, not between toes -Trim toenails when needed -Don’t use hot water bottles, heating pads, or electric blankets on their feet 1.American Diabetes Association. Foot care. http://www.diabetes.org/living-with-diabetes/complications/foot-complications/foot-care.html. Accessed July 3, 2014.http://www.diabetes.org/living-with-diabetes/complications/foot-complications/foot-care.html 2.Jones RM, Wilson CE. Assessing the diabetic patient. US Pharmacist. 2011. http://legacy.uspharmacist.com/oldformat.asp?url=newlook/files/Feat/ACF2E98.cfm&pub_id=8&article_id=11. Accessed June 19, 2014. http://legacy.uspharmacist.com/oldformat.asp?url=newlook/files/Feat/ACF2E98.cfm&pub_id=8&article_id=11

18. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 18 Keep Eyes Healthy 1 Discuss with your patients The importance of an annual dilated eye examination (diabetes is the leading cause of blindness in adults) Blood sugar and blood pressure levels Eye exams can detect – Glaucoma – Cataracts – Other eye problems A few questions to ask your patients Is your vision blurry? Do you have trouble reading signs or books Do you see double Do your eyes hurt Do you feel pressure in your eyes Do you see spots or floaters 1.American Diabetes Association. Eye care. http://www.diabetes.org/living-with-diabetes/complications/eye-complications/eye-care.html. Accessed July 2, 2014.http://www.diabetes.org/living-with-diabetes/complications/eye-complications/eye-care.html

19. © 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.14.06.044 Thank you for what you already do to assist your patients with diabetes. Comments?/Questions? 19