Role of Pharmacist in Education and Monitoring of Drug Therapy on Self Management and Blood

Glucose Profile in Patients with Diabetes Mellitus Type II in Denpasar

Sarasmita, M.A1, Larasanty, F.L.P1, Puspita Sari, R.A.D1

1
Pharmacy Department Faculty of Mathematics and Natural Sciences Udayana University, Bali

Correspondence: Made Ary Sarasmita

Department of Pharmacy Faculty of Mathematics Udayana University, Bali
Arysarasmita@yahoo.com

According to Indonesian Health Research which held by Ministry of Health Republic of Indonesia in 2013,
the prevalence of Diabetes Mellitus (DM) type II in Bali was ranked 10th out of 33 provinces in Indonesia.
Pharmacists play a role in educating and monitoring drug therapy. The success of education was seen by
the result of therapy such as self management and controlled blood glucose level. The objectives of the
study analyzed the education and monitoring of drug therapy on improvement of blood glucose profile of
DM type II patients. Observational study was held at the Polyclinic in Wangaya Hospital Denpasar during
January-April 2016. Blood glucose improvement data were analyzed by Shapiro-Wilk test and paired t-test.
The instruments were educational leaflet and questionnaire Summary Diabetes Self Care Activities. From
75 patients, as many as 16 patients participated in the study and 4 patients dropped out, so that obtained 12
patients. As many as 50% of patients aged ≥65 years and dominated by men (58.33%). The patient's
treatment profile were biguanid (25%), biguanid + sulfonylurea (41,67%), insulin rapid + long acting
(16,67%), insulin rapid (8,3%) and long acting insulin (8,3%) . Results of drug therapy monitoring as many
as 12 patients were appropriately indications, right medication, right patient and right dose. The result of
paired t-test obtained p-value <0,05 in month 1-2, month 1-3 and month 1-4. The mean fasting blood
glucose decreased by 151 mg/dl to 139,33 mg/dl (month 2, mean 23,65), 125,66 mg/dl (month 3, mean
27,64), 123,25 mg/dl (month 4, mean 32,81). The mean postprandial blood glucose decreased, the first
month by 238 mg/dl to 199.33 mg/dl (month 2, mean 40,88), 179,55 mg/dl (month 3, mean 39,76), 179,83
mg/dl (month 4, mean 66.18). Education improves self-management and improves blood glucose profile in
patient with type II DM. These changes support the success of DM therapy.

Keywords: pharmacist, diabetes mellitus type II, education, blood glucose, self-management
1. Background

Diabetes Mellitus (DM) is a syndrome of metabolic disorders with sign of hyperglycemia. DM can
trigger the onset of serious complications in macrovascular and microvascular diseases. From data
Indonesian Health Research in 2013, the case of Diabetes Mellitus in Bali province ranked 10 th out of 33
provinces in Indonesia. According to the Directorate General of Pharmaceutical Care (2009),
pharmaceutical services require to provide health education as part of the recommendation of therapy. The
success of the pharmacist in providing patient education is seen from the goals of therapy (outcome) in the
form of increased self-management and control of fasting blood glucose (FBG), post prandial blood glucose
(PPBG) and random blood glucose (RBG) approach the expected criteria (Karlsen et al., 2004). Provision
of education in this study include lifestyle, checking blood glucose levels, foot care, drug use and physical
exercise.
Icwari (2013) and Suryani (2013) showed related to pharmacy service in chronic disease sufferers by
Apothecary at Wangaya Hospital. There is a strong influence to patient behavior change. In patients with
type II diabetes mellitus without complications and patients with complications, there is a decrease in blood
glucose levels up to <200 mg / dl (Icwari, 2013; Syria, 2013). This indicates that the pharmacist has a very
important role in efforts to improve the quality of life of patients. In the era of Indonesian National Health
Insurance, it has launched a program management of chronic Diabetes Mellitus Type 2 (DM Type 2) or so-
called Prolanis. This program is a place for pharmacists to contribute, to support and play a role in
improving the quality of life of patients. Pharmacists have an important role in the Monitoring of Drug
Therapy. Drug Treatment Monitoring process is a comprehensive process ranging from patient selection,
patient data collection, identification of drug-related issues, therapeutic recommendations, monitoring plans
to follow-up. The process should be carried out continuously until therapeutic goals are achieved.

2. Aim

Analyze the education from pharmacist and monitoring of drug therapy on improvement of self-
management and blood glucose profile of type II Diabetes Mellitus in Wangaya Hospital, Denpasar in the
era of Indonesian National Health Insurance.

3. Method

Observational research with quantitative descriptive type is done by consecutive sampling technique.
Datas were collected from questionnaire and patient medical record. Then, a statistical analysis with
statistical normality test Kolmogrov Smirnov (test of normality), paired t-test was used to test the average
blood glucose levels before and after education. The study was conducted at the Pharmacy and Internal
Medicine Clinic of Wangaya Hospital Denpasar, Bali Province in December 2015 until March 2016.
Inclusion criteria of subjects include type II Diabetes Mellitus patients, patients who were willing to
participate in the study, age > 18 years, patients who were receiving oral and insulin antidiabetes drugs, and
patients who did not experience complications of the disease. The instruments of education were leaflets.
Leaflets contain the definition of Diabetes Mellitus disease, eating patterns for Type II Diabetes Mellitus
patients, caring for feet, checking blood glucose levels independently and information on the procedures
for the use of antidiabetic drugs. Questionnaires were used to monitor the level of self-management of
patients. SDSCA questionnaire (Summary Diabetes Self Care Activities) was used. There are 5 question
items in the questionnaire including dietary activity, exercise, blood glucose measurement, foot care and
therapy (Toobert J, et al., 2000).
The research has received permission from Committee of Ethics and Research Development of Faculty
of Medicine, Udayana University / Sanglah General Hospital Denpasar. The selection of the subjects was
done in the Internal Medicine Clinic of Wangaya Hospital Denpasar. Patients who met the inclusion criteria
and agreed to participate in the research signed the informed consent sheet. The patient's demographic data
includes the number, name of identity, address, age, history of history, diagnosis, history of disease and
medical history obtained from the patient's medical records (PMR) and collected as preliminary
information.
3.1 Data collection
Data collected and formed as demographic data, and also observational result of patient self management
level and examination result of blood glucose level before and after education.
3.2 Data Analysis
Pre-education results data would be compared with data after education and analyzed changes in self-
management and blood glucose profile in the patients. The parameters measured were self-management
and blood glucose profile (RBG, PPBG, FBG). In addition, a review analysis of drug therapy obtained from
patient treatment data (medical record). Then, data was analyzed descriptively and presented in categorical
form to show the change of parameters measured in Type 2 Diabetes Mellitus patient in JKN era. The data
obtained then performed statistical analysis to measure whether there was a significant difference between
blood glucose profiles before and after treatment monitoring a paired t-test was performed.

4.1 Result and Disscusion

4.1 Socio-Demographic Characteristics
There were total of 75 patients with type 2 Diabetes Mellitus without complications who
undergone outpatient at Internal Polyclinic RSUD Wangaya Denpasar. Based on the inclusion criteria
obtained 16 patients who participated in the study. Monitoring of self-management, blood glucose profile,
and type of treatment of patients for 4 months (January-April 2016). As the study progressed, 4 patients
dropped out because subjects checked their blood glucose levels differently each month so that blood
glucose levels could not be used. The socio-demographic characteristics of the patients shown were
characteristic based on age, sex, last education, duration of diabetes and fasting and post prandial blood
glucose profile before being given education.
Most of the patients (50%) were ≥ 65 years old. Diabetes mellitus patients tend to increase with
increasing age as insulin secretion by the pancreas also decreases (D.W. Dunstan et al., 2002). Patients
involved in the study were only 12 people so that they could not reflect the overall condition of the
population. Respondents were dominated by male patients (58,33%). Type of sex become one of the factors
associated with the occurrence of diabetes mellitus type 2. This is in line with the Icwari research in 2013,
patients with diabetes melitus type 2 without complications that went to the internal polyclinic RSUD
Wangaya Denpasar were dominated by men (55,19%), while female patients equal to 44,81%. This is
because the risk of men to suffer central obesity is higher than in women. Obesity will occur fat
accumulation that can inhibit the work of insulin so that glucose can not be transported into the cell thus
increasing the occurrence of DM (Pinkney, 2001)
In terms of education, patients with uncontrolled fasting blood glucose levels (≥126 mg/dl) were
dominated by non-schoolers and those with a primary and junior secondary education level. As education
increases, fasting blood glucose control is improved. This can be due to the level of education associated
with an understanding of the importance of self-management behavior (Bai, Chiou & Chang, 2009).
Duration of diabetes mellitus is dominated by patient for 1 year (66,67%). The duration of DM is associated
with complications. If people with type 2 diabetes mellitus do not get the right treatment then it will slowly
lead to more serious complications (Tjay and Rahardja, 2007)
 50 %
58,33 %
50
60 41,67%
40
Percentage

25 %

Percentage
30 40
16,67 %
20
8,33 % 20
10
0
0
36 – 45 46 – 55 56 – 65 ≥ 65 Male Female
Age (years old) Sex Type

(A) (B)
100 % 100 % 100 %
66,67 %
Patient Percentage with Fasting

100 80
Blood Glucose ≥ 126 mg/dl

80 60 % 60

Persentase
50 %
60 40 25 %
40 16,67 %
20
20
0
0
< 1 year 1 year > 1 year
Never Primary Junor Senior College
gone to School High High
school School School
Length of Diabetes Mellitus Suffer
Formal Education Level
(C) (D)
Figure 4.1 Patient Characteristic based on age(A), sex type (B), formal education level (C) nad Length of
Diabetes Mellitus Suffers (D).

Subjects routinely checked fasting blood glucose and post prandial blood glucose in Internal
Polyclinic of RSUD Wangaya Denpasar every month. Most of respondent have fasting blood glucose
profile above normal (≥126 mg/dl) that is equal to 58,33% whereas respondent who have post prandial
blood glucose profile above normal (≥200 mg/dl) that is equal to 58,33% and the rest subjects have fasting
and post prandial blood glucose levels within the normal range. Uncontrolled blood glucose levels of this
patient shows that patients need to be given education to support pharmacological therapy with oral
antidiabetes or insulin.

58,33 % 58,33%
41,66 %
60 41,66 % 60

40
Percentage

40
Percentage

20
20
0
0 ˂ 200mg/dl ≥ 200 mg/dl
˂ 126 mg/dl ≥ 126 mg/dl
Fasting Blood Glucose Level Post Prandial Blood Glucose Level

(A) (B)

Figure 4.2 Patient characteristic based on blood glucose level : fasting blood glucose (A) and post
prandial blood glucose (B) before given education.
4.2 Profile of Antidiabetic Drugs Therapy
The profile of diabetes mellitus type II therapy consists of oral antidiabetes and insulin. There
were 3 patients who had treated with biguanid antidiabetic drugs (metformin). American Diabetes
Association (ADA) consensus in 2008 showed that metformin was recommended as first-line drug therapy
for all type II diabetic mellitus except for contraindications to metformin (Lee FT, 2009). The choice of
metformin was based on fasting blood glucose and postpartum blood glucose for three months or longer.
Five patients were given combination therapy between biguanide (metformin) and sulfonylurea
(glimepiride). This combination is most widely used in patients who are treated to internal polyclinic RSUD
Wangaya Denpasar (41.67%). Antidiabetic drug combinations is given if the patient's blood glucose levels
are not controlled with monotherapy. Drug combination aims to improve the effectiveness of therapy and
reduce the side effects of the drug. Treatment with a combination of drugs should be selected two kinds of
drugs from drug classes that have different working mechanisms (Perkeni, 2011)
Patients treated with long acting insulin have uncontrolled fasting blood glucose levels (> 126
mg/dl), in addition patients who used basal insulin have been included in elderly (83 years). Provision of
basal insulin supports comfortness because it takes only once injection a day. Another type of insulin
prescribed by a doctor is insulin rapid acting. If the target of basal or fasting blood glucose has been
achieved, while the HbA1C levels have not reached the target then performed post prandial blood glucose
control. Insulin used to achieve the target of post prandial blood glucose is rapid acting insulin (rapid acting)
(Perkeni, 2011). The combination of rapid acting insulin and long acting insulin is the most widely
prescribed insulin combination by doctors. Combined insulin therapy is tailored to individual needs and
responses assessed by blood glucose levels (Perkeni, 2011). The addition of prandial insulin to basal insulin
may result in better glycemic control and less variation in blood glucose levels (Hamaty, 2011)

41,67 %
45
40
35
25 %
30
Persentase

25 16,67 %
20
15 8,3 % 8,3%
10
5
0
Biguanide Biguanide + Insulin Insulin Insulin
Sulfoilurea Rapid Rapid Long Acting
Acting + Acting
Long Acting
Antidiabetic Drugs Therapy Profile in Patients

Figure 4.3 Profile of Antidiabetic Drug Therapy in Patient Diabetes Mellitus Type II without
Complication in Wangaya Hospital Denpasar period January to April 2016.

4.3 Analysis of Rational Drug Therapy

Proper administration of antidiabetic drugs is of great importance while the warning of
complications that can be occured when diabetes mellitus is not handled appropriately. Therefore, diabetic
therapy should be done rationally. Rationality of drug use can be assessed based on criteria established by
the World Health Organization (WHO). Data on the evaluation table of patient accuracy shows that in
January - April 2016, therapy received by 12 patients in this study was appropriate indication, correct drug,
exact patient and exact dose. The following discussed the accuracy of drug use as well as alertness to drug
side effects.
4.3.1 Right Indication
Right indication is right use of antidiabetic drugs based on established diagnosis, in accordance with the
diagnosis listed in the medical record and patients who have fasting blood glucose level ≥126 mg / dl and
have post prandial blood glucose level ≥ 200 mg / dl. Based on the data, subjects who were diagnosed with
type 2 diabetes mellitus as many as 12 patients. Fasting blood glucose data of all patients since the first
diagnosis of diabetes mellitus ± 350 mg / dl and given the drug in accordance with the diagnosis. In this
study the patient included in the exact indication of as many as 12 patients (100%).
4.3.2 Right Drug
Based on the right diagnosis, the right drug selection should be made. The drug should also prove its benefits
and safety. The accuracy of the drug is the appropriateness of antidiabetic drug with standard used as
guidelines (guideline) therapy at RSUD Wangaya Denpasar City, which is performed in Perkeni Guideline
2011 is equal to 100%. This is consistent with the algorithm of Perkeni 2011 which states that
pharmacological therapy of type II diabetes mellitus is first used oral antidiabetic, if blood glucose levels
can not be controlled then used combination oral antidiabetic drugs (Perkeni, 2011).
4.3.3 Right Dose
Right dose is the accuracy of dose selection and frequency of use of antidiabetic drugs with Perkeni 2011
standard used as therapy guidance in Wangaya Hospital. Administration of doses in patients taking oral
medication and insulin therapy has been in accordance with the dose of daily administration (Practical
Guide to Insulin Therapy in Type 2 Diabetes Mellitus 2011 and Consensus of Indonesian Endocrinology
Society 2011). The treatment of type 2 diabetes outpatient in Wangaya Hospital during January-April 2016
period was 100% accurate dose based on Perkeni 2011 standard. The accuracy of drug dosage could be
seen from the conformity of standard dosing and dosage at guide line therapy used at RSUD Wangaya.
4. Right Patients
The right patient is the provision of antidiabetic drugs that must be adapted to the circumstances of each
patient. Based on medical record data obtained, type 2 diabetes mellitus at RSUD Wangaya Denpasar has
no contraindication with oral antidiabetes drug or insulin. The use of single antidiabetic drugs (metformin)
has been appropriate in patients who have fasting blood glucose and post prandial. Three people with
diabetes mellitus were treated with a single antidiabetic drug because HbA1C levels have reached the
therapeutic target of <7%. The use of a combination of antidiabetic drugs has also been appropriate in
patients who have fasting blood glucose and post prandial who have not reached the target when treated
with a single drug (metformin). Patients treated with combination drugs had fasting blood glucose levels >
70-130 mg / dl and post prandial glucose levels > 180 mg / dl.
The long acting insulin is used on patient who have uncontrolled fasting blood glucose levels are > 126 mg
/ dl, in addition, the subjects entered the category of elderly (83 years). Patients with elderly will depend on
others to facilitate the injection of insulin, therefore the usage of long-acting insulin is more comfortable
(Gupta V and Suri P, 2002). In addition, long acting insulin is approriate in elderly patients because the
body's physiological system such as kidney function began to decline, so that metformin is not
recommended in the elderly (> 80 years) (Wallace JI, 1999). Elderly patients are also not recommended to
be treated with sulfonylurea drugs, because sulfonylureas can cause hypoglycemia (Lee FT, 2009).
The use of combination insulin has been appropriate with the condition of the patient who have fasting
blood glucose and post prandial ranged between 220-360 mg / dl. These patients have experienced severe
hyperglycemia so that HbA1C levels are > 7.5%. From the description above the use of drugs has been in
accordance with the condition of the patient so that the use of antidiabetes drugs has been 100% appropriate
patient.
5. Beware of Side Effects
Side effects of antidiabetic drugs are hypoglycemia. From 12 patients who participated in this study, only
3 patients who know the side effects of antidiabetic drugs (hypoglycemia) through questionnaire collection.
Patients who have experienced hypoglycemia as much as 2 patients and patients who know how to handle
hypoglycemia is only 1 person. However, vigilance against the side effects of drugs increases every month.
This is due to the education has been given periodically, so the patient began to know about the side effects
of drugs and how to overcome them.

4.4 Improvement in Self-Management After Education

In this study, improvement in self-management is used as an indicator to evaluate the success of education
in patients with type II DM. Education includes diet settings, physical exercise, blood glucose examination,
drug use and foot care. Provision of education to patients is done 4 times from January to April 2016.
Summary of Diabetes Self-Care Activities-Revised (SDSCA) instrument is a self-report of self-
management briefly in diabetes that consists of question items to assess aspects of diabetes care including
diet, exercise, blood glucose measurement, foot care and therapy (Toobert J, et al., 2000). Questionnaire
contains 16 questions consisting of 5 categories of questions. The answers of each question are assessed by
the number of days in a week of 0 to 7. The total points of the self-management questionnaire are 112 with
the maximum points differing from each question category. Maximum diet category score 35, sport 7, blood
glucose measurement 14, drug use 21 and category of maximal foot care points 35.
Patient’s self-management data before being educated has a normal distribution after a normality test using
Shapiro-Wilk. Test of correlation of self-management results using Correlation Product Moment with
Pearson formula. The correlation test results obtained that the self-management in months 1-2 and 1-3
strongly correlated (value r 0.684 and 0.778) and months 1-4 moderately correlated (value r 0.586), then it
can be showed that there is a correlation between self-management before and after education. The result
of the analysis by using paired T test showed significance value 0,001 (p-value <0,05) at month 1-2, then
got significance value 0,000 (p-value <0,05) at month 1-3 and last obtained value Significancy 0,000 (p-
value <0.05) in 1-4 months. From these data it can be concluded that there are significant differences in
self-management activities in patients with type II DM before and after being given education.
The results of this study are in line with Funnel theory (2012) which states that education provided through
diabetes self-management education can facilitate and increase knowledge, skills and abilities of DM
patients in self-managing themselves. Indicators of drug usage have the highest percentage increase
compared to other indicators. This can be caused by patients who participated in the study were dominated
over age 45 years old. Patients with older age (> 45 years) will pay more attention to the treatment. This is
in line with Ramadona's (2011) study which suggests that older sufferers exhibit a better attitude change
compared to younger patients.

Table 4.1 Improvement of Self-Management

Self Management
Mean
Criteria
Month % Month % Month % Month %
1 2 3 4
Diet Setting 23,67 67,62 30,75 87,85 33,5 95,71 33,5 95,71
Physical Exercise 1,58 11,28 2,91 41,57 4,25 60,71 6,25 89,28
Control of Blood
1,75 12,5 3,41 24,35 6,25 44,64 7,08 50,57
Glucose
Drug Usage 20,5 97,61 21 100 21 100 21 100
Foot care 14,75 42,14 19,25 55 23,08 65,94 26,5 75,71
Keterangan :
n : 12 patients
total point 1 indicator px1+ total point 1 indicator px2+⋯……..........+ total point 1indicator px12
rerata :
12
% : Percent of mean from each indication
Increasing the percentage of dietary indicators indicates that changes occur after being educated.
According to Dalimartha & Adrian (2012), diet is the basis of the management of type II DM because of
problems that occur in patients with type 2 diabetes that occurs insulin resistance by the body and relative
insulin deficiency that causes hyperglycemia (International Diabetes Federation, 2011). Diabetic foot ulcer
are considered a complication of DM. Several studies have shown that educational intervention for patients
about foot care is very effective in prevention of diabetic foot ulcers (Aalaa et al., 2012). Sports activities
increased as education granted for 4 months. The type of exercise done by all subjects is walking. According
to Dalimartha & Adrian (2012), the recommended exercise is aerobic exercise, such as walking, jogging,
casual cycling, rhythmic gymnastics, and swimming. Regular exercise for more than 8 weeks on DM type
II clients has been shown in decreasing HbA1c levels (Sigal et al, 2006). Blood glucose examination
indicator has the lowest percentage. This can be due to the unavailability of a tool to perform blood glucose
examination. The examination of blood glucose levels is recommended at least two to three times per week
(Smeltzer & Bare, 2001). Most of the respondents in this study (83.3%) answered did not check their own
blood glucose test regularly.

4.4 Changes in Blood Glucose Levels Patients After Education

In this study, changes in blood glucose levels were used as indicators to evaluate the efficacy of
education in people with type II DM. FBG data of month 1 and 4 patients were normally distributed
(p>0.05), but in months 2 and 3 the data were not normally distributed (p<0.05). Thus significant changes
were tested with the wilcoxon test (non-parametric). PPBG data for 4 months patients had normal
distribution after normality test using Shapiro-Wilk. The correlation of the patient's FBG data was tested
by the pearson formula and it was found that in 1-2 months, months 1-3 and 1-4 months the correlations
fall into strong correlated categories (r values 0.921, 0.888 and 0.867). While the correlation test on PPBG
data in months 1-2 and 1-3 showed as strong correlation category (r value of 0.810 and 0.837) and month
1-4 correlates into medium category (value r 0,400).

Table 4.2 Comparison of Self-Management before and after diabetes self-management education.

Self Management
N P
Mean
Month 1 12,45
12 0,01
Month 2 15,48
Month 1 12,45
12 0,00
Month 3 17,65
Month 1 12,45
12 0,00
Month 4 18,90
Keterangan:
N : Subjects (patients)
P : Significancy number
P<0,05 : Significally comparation value

After being given education, the average value of fasting blood glucose in the first month
decreased. The average first month of fasting blood glycate 151,83 mg/dl decreased to 139,33 mg/dl
(second month), 125,66 mg/dl (third month), 123,25 mg/dl (fourth month). The mean value of post prandial
blood glucose also decreased after being educated. The first month of post prandial glycemic blood granate
238 mg/dl decreased to 199,33 mg/dl (second month), 179,55 mg/dl (third month), 179, 83 mg/dl (fourth
month). In the fourth month, the post prandial blood glucose level was greater than the third month but
blood glucose was controlled when compared with the first month before being educated.
 Table 4.3. Mean Result on fasting and postprandial blood glucose before given education.

Mean
1st Month 2nd Month 3rd Month 4th Month
Fasting blood glucose 151,83 139,33 125,66 123,25
Post prandial blood
238 199,33 179,55 179,83
glucose

Results from the table above stated that in month 1 (control) – month 2 did not change fasting
blood glucose significantly with significance value 0,094 (p-value>0,05). Whereas in 1-3 months and 1-4
there was a significant change in the repair of blood glucose patients before and after being given education
with p-value <0,05. This is because the process of behavior change is the result of a complex, takes a long
time (Notoatmodjo, 2010).

Table 4.4. Mean Result of Reduction on Fasting Blood Glucose Level Before and After Given Education
Reduction of Fasting Blood Glucose Level
N Mean P
Month 1
12 23,65 0,099
Month 2
Month 1
12 27,64 0,010
Month 3
Month 1
12 32,81 0,010
Month 4
Keterangan:
N : Subjects (patients)
P Significancy number
P<0,05 : Significally comparation value

Table 4.5. Mean Result of Reduction on Fasting Blood Glucose Level Before and After Given Education.
Reduction of Post Prandial Blood Glucose Level
N Mean P
Control
12 40,88 0,007
(Month 2)
Control
12 39,76 0,00
( Month 3)
Control
12 66,18 0,01
( Month 4)
Keterangan:
N : Subjects (patients)
P Significancy number
P<0,05 : Significally comparation value

Paired t-test on post prandial blood glucose value obtained p-value <0,05 so it can be concluded that in the
first month until last month there was a significant difference in the improvement of blood glucose of DM
type II patient before and after being given education. This is in line with the research of Sesilia Andriani
Keban, et al (2013) which states that pharmacist education can improve knowledge and medication
adherence.
The use of drugs in patients who are involved in this study has been in accordance with the POR (Rational
Drug Use) is precise indication, exact patient, proper medication, proper dose and alert side effects.
However, blood glucose levels of patients have not been well controlled. Provision of education affects the
change in self-management of patients with type II diabetes without complications and improvement of
fasting blood glucose and post prandial. There are differences in self-management and significant
improvement of blood glucose in patients with DM after being given patient education in 4-month time
interval. Education has proven to be important in efforts to improve knowledge, adherence, and glycemic
control in patients with DM (Jenhani et al., 2005)

5. Conclusions
Education improves self-management and improves blood glucose profile of type II DM patients. These
changes support the success of DM therapy.

6. Acknowledgments
Acknowledgments to Udayana University's Research and Community Service, Pharmaceutical Faculty of
Mathematics and Natural Sciences Udayana University, and Wangaya Denpasar Regional General Hospital

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