Impact of clinical pharmacist integration on diabetes management: a prospective cohort
Prediabetes and type II diabetes mellitus(TIIDM) are chronic conditions that can significantly impact an individual’s quality of life. Individuals with diabetes face a significantly increased risk of cardiovascular events, with up to a two- to three-fold higher likelihood of experiencing a heart attack or stroke compared to those without the disease . Patients typically require periodic follow-ups to monitor the progression of the disease, and adherence to these follow-ups is critical to successful treatment outcomes. Careful monitoring of treatment is important, as early detection and management of microvascular complications associated with TIIDM, and can greatly reduce their impact and improve patient outcomes . Patient education and information dissemination have proven effective in increasing patient awareness of the importance of symptom control. Optimizing the treatment in patients with prediabetes and TIIDM requires patient education and counselling, with the primary goal of improving glycemic control while maintaining neutral or positive effects on lipid levels and blood pressure. Selecting appropriate medications for treatment involves careful consideration of potential drug interactions, side effects, and patient compliance . Pharmaceutical care is a comprehensive approach to drug therapy management, aimed at achieving desirable clinical outcomes to enhance patients’ quality of life . The optimal management of prediabetes and TIIDM often involves a team-based approach. Integrating clinical pharmacists into these teams has been shown to enhance the effectiveness of treatment. Clinical pharmacists play a valuable role in prediabetes and TIIDM care, as enhance outcomes by optimizing medication effectiveness, minimizing side effects, and preventing drug interactions. Clinical pharmacy is a crucial field that focuses on enhancing drug therapy, healthcare. It involves patient care, medication optimization, and monitoring. Clinical pharmacists (CP) are experts in medication use, offering prescription oversight, care planning, patient education, and adverse reaction reporting. Their role includes collaborating with healthcare professionals, making recommendations, and educating patients for safe and effective medication use . This practice ensures accurate, cost-efficient drug use through a blend of skills including disease understanding, drug knowledge, communication, and research. CPs’ expertise influences treatment decisions, ensuring cost-effective plans that prioritize benefits and risks. Patient education by CPs fosters understanding of medications, administration, and expected effects, thus improving adherence and overall treatment success . There is a growing need for CPs to take more prominent role in the care of patients with prediabetes and TIIDM through the implementation of pharmaceutical care. Current literature has shown that pharmacist-based interventions are effective in supporting patients’ treatment, thus highlighting the importance of integrating CPs into prediabetes and TIIDM care teams . This study aims to assess the impact of CP interventions on the management of prediabetes and TIIDM by examining disease perceptions, knowledge levels, and the evolving role of pharmacists in optimizing treatment outcomes.   Design, sample size and patient characteristics The present study is designed as a prospective, cohort study. This study was designed to investigate the effects of patient-oriented pharmacy services provided by the CP on prediabetes and TIIDM. Patients included in our study were selected using a probabilistic convenient sampling method. Thus, the two groups, included the patients with prediabetes (pDG) and those with TIIDM (DMG). Ethical approval was obtained from the local Ethics Committee with decision number 2021/306. The study was conducted between 27.07.2021 and 30.04.2022 on patients diagnosed with prediabetes or type II diabetes mellitus by the internal medicine specialist according to the American Diabetes Association (ADA) 2021 criteria who applied at the Internal Medicine Outpatient Clinic of Bezmialem Vakif University hospital in Istanbul . The prediabetes and TIIDM patients were informed about the study and included in the study after obtaining signed informed consent. The inclusion criteria were: diagnosis of prediabetes or TIIDM, being ≥ 18 years old, and signing the informed consent form. Exclusion criteria were: declining to sign consent form, diagnosis of Type-I diabetes, lack of necessary cognitive abilities, and being <18 years old. The sample size was determined based on the number of patients meeting the inclusion criteria within the study period . With an alpha (α) of 0.05 and a beta (β) of 0.95, the study achieved a power of 93.54% by including a minimum of 55 participants for pDG and DMG groups. This study is reported according to the recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) standards . Clinical pharmacist intervention At the first visit (day 0), a detailed patient profile was recorded containing sociodemographic characteristics of the patients, current medical conditions, blood glucose, glycosylated hemoglobin levels(HbA1c), Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), serum creatinine, urea, blood urea nitrogen, total cholesterol, LDL and HDL cholesterol levels, waist circumference measurement, complete blood counts by the CP. Furthermore, patients’ self-reports and electronic health records were utilized to collect information on prediabetes, TIIDM, and treatment for TIIDM within the past month. Illness Perception Questionnaire-revised (IPQ-R) and knowledge level questionnaires (Diabetes Knowledge Measurement Questionnaire, Prediabetes Knowledge Measurement Questionnaire) were applied by the CP to participants. The assessment of patient illness perception for prediabetes and TIIDM through eight items following patient education was conducted using the Turkish version of the Illness Perception Questionnaire-revised (IPQ-R). The IPQ-R was prepared with modifications of questionnaire prepared and validated by Weinman et al.  and Moss-Morris et al. . Özkan et al.  conducted cross-cultural adaptation and assessed the validity and reliability of the Turkish version of the IPQ-R questionnaire. The IPQ-R consists of three components: illness representation, identity, and cause. The questionnaire was designed with questions that were appropriate assess the knowledge and understanding levels of the patients. The items of IPQ-R are scored between 1–10. As the mean of the IPQ-R scale move towards lower scores, it is accepted that disease perception increases. Diabetes knowledge measurement questionnaire (DKMQ) consisted of 18 yes/no questions pertaining to the characteristics, symptoms, complications, treatment options, and regular controls of diabetes with yes/no answers. Prediabetes knowledge measurement questionnaire (PKMQ) included 18 yes/no questions related to the characteristics of prediabetes, symptoms, risk factors, prevention methods, and the status of conversion of prediabetes to diabetes. The DKMQ and PKMQ were specifically developed by our research team but was not validated (Cronbach’s alpha and ICC values of DKMQ [Cronbach’s alpha: 0.910; ICC: 0.836 (95% CI: 0.754–0.892; p < 0.001)] and PKMQ [Cronbach’s alpha:0.691; ICC: 0.528 (95% CI: 0.329–0.682; p < 0.001)] has been evaluated), drawing upon a comprehensive review of the existing literature and leveraging the team’s extensive expertise in the field. The development process included contributions from two clinical pharmacists, one internal medicine specialist, one clinical pharmacy master’s student, and one neuroscientist. DKMQ and PKMQ are calculated on a percentage basis, with higher scores associated with higher levels of knowledge. The questionnaires were administered face-to-face by a clinical pharmacist on days 0 and 90. These tools were utilized to provide comprehensive insight into the sociodemographic characteristics, disease perception, and knowledge levels of patients with prediabetes or diabetes. The data obtained through these questionnaires and scales were analysed to draw meaningful conclusions and recommendations. During the first interview a type III medication review and a structured oral and written patient education was given to participants by clinical pharmacist, lasted approximately 15 min each interview. Type III clinical medication review focuses on issues related to a patient’s use of medicines within the context of their clinical conditions. This review always involves interviewing the patient and includes access to relevant patient information, such as clinical conditions and laboratory test results. It encompasses an evaluation of both medications and health conditions . Patients were provided with brochures specifically developed by the researchers for prediabetes and TIIDM to ensure standardization. The educational materials were developed with consideration for cultural and demographic differences, drawing from current literature to ensure relevance and inclusivity . Patient education included information regarding the disease definitions and types, symptoms, conditions that may occur in the body due to prediabetes and TIIDM, routine tests that should be performed, and risk factors. The aim of these educational sessions was to provide patients with accurate information about their disease and treatment process and to encourage them to take the necessary measures to keep these diseases under control, thus preventing the transition of prediabetes to TIIDM and avoiding complications that may arise from uncontrolled TIIDM. In addition, a reminder telephone interview was performed by the CP at the end of the 1st month, including key points of patient education provided by the CP. At second interview (day 90), in addition to waist circumference measurement and lab values, disease perception and knowledge level questionnaires were readministered by the CP. The questionnaires were used to measure changes in the knowledge levels and perceptions of patients with prediabetes or TIIDM. The primary outcome measures were the change of blood glucose, HbA1c levels, HOMA-IR, serum creatinine, urea, blood urea nitrogen, total cholesterol, LDL and HDL cholesterol levels, waist circumference measurement, complete blood counts, difference on patients’ disease perceptions and knowledge levels of patients about prediabetes and TIIDM. Data analysis Demographic data were presented as percentages, while continuous and discrete variables were reported using descriptive statistics such as mean, standard deviation, standard error, median, interquartile range, and mode. The missing data is excluded from the analysis. The significance of assessing patients’ knowledge regarding prediabetes or TIIDM treatment was determined using the Chi-Square or Fisher's exact tests. Changes in routine laboratory measurements, including blood glucose, glycosylated haemoglobin, and HOMA-IR levels, over 90-day intervals were analysed. To investigate the possible association between variables, the Mann–Whitney U and Wilcoxon signed rank tests were employed after assessing the results of the Kolmogorov–Smirnov test. Statistical analysis was performed using SPSS 26.0 and Jamovi software. Statistical significance was indicated by p < 0.05 at a 95% confidence interval.   The present study is designed as a prospective, cohort study. This study was designed to investigate the effects of patient-oriented pharmacy services provided by the CP on prediabetes and TIIDM. Patients included in our study were selected using a probabilistic convenient sampling method. Thus, the two groups, included the patients with prediabetes (pDG) and those with TIIDM (DMG). Ethical approval was obtained from the local Ethics Committee with decision number 2021/306. The study was conducted between 27.07.2021 and 30.04.2022 on patients diagnosed with prediabetes or type II diabetes mellitus by the internal medicine specialist according to the American Diabetes Association (ADA) 2021 criteria who applied at the Internal Medicine Outpatient Clinic of Bezmialem Vakif University hospital in Istanbul . The prediabetes and TIIDM patients were informed about the study and included in the study after obtaining signed informed consent. The inclusion criteria were: diagnosis of prediabetes or TIIDM, being ≥ 18 years old, and signing the informed consent form. Exclusion criteria were: declining to sign consent form, diagnosis of Type-I diabetes, lack of necessary cognitive abilities, and being <18 years old. The sample size was determined based on the number of patients meeting the inclusion criteria within the study period . With an alpha (α) of 0.05 and a beta (β) of 0.95, the study achieved a power of 93.54% by including a minimum of 55 participants for pDG and DMG groups. This study is reported according to the recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) standards .   At the first visit (day 0), a detailed patient profile was recorded containing sociodemographic characteristics of the patients, current medical conditions, blood glucose, glycosylated hemoglobin levels(HbA1c), Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), serum creatinine, urea, blood urea nitrogen, total cholesterol, LDL and HDL cholesterol levels, waist circumference measurement, complete blood counts by the CP. Furthermore, patients’ self-reports and electronic health records were utilized to collect information on prediabetes, TIIDM, and treatment for TIIDM within the past month. Illness Perception Questionnaire-revised (IPQ-R) and knowledge level questionnaires (Diabetes Knowledge Measurement Questionnaire, Prediabetes Knowledge Measurement Questionnaire) were applied by the CP to participants. The assessment of patient illness perception for prediabetes and TIIDM through eight items following patient education was conducted using the Turkish version of the Illness Perception Questionnaire-revised (IPQ-R). The IPQ-R was prepared with modifications of questionnaire prepared and validated by Weinman et al.  and Moss-Morris et al. . Özkan et al.  conducted cross-cultural adaptation and assessed the validity and reliability of the Turkish version of the IPQ-R questionnaire. The IPQ-R consists of three components: illness representation, identity, and cause. The questionnaire was designed with questions that were appropriate assess the knowledge and understanding levels of the patients. The items of IPQ-R are scored between 1–10. As the mean of the IPQ-R scale move towards lower scores, it is accepted that disease perception increases. Diabetes knowledge measurement questionnaire (DKMQ) consisted of 18 yes/no questions pertaining to the characteristics, symptoms, complications, treatment options, and regular controls of diabetes with yes/no answers. Prediabetes knowledge measurement questionnaire (PKMQ) included 18 yes/no questions related to the characteristics of prediabetes, symptoms, risk factors, prevention methods, and the status of conversion of prediabetes to diabetes. The DKMQ and PKMQ were specifically developed by our research team but was not validated (Cronbach’s alpha and ICC values of DKMQ [Cronbach’s alpha: 0.910; ICC: 0.836 (95% CI: 0.754–0.892; p < 0.001)] and PKMQ [Cronbach’s alpha:0.691; ICC: 0.528 (95% CI: 0.329–0.682; p < 0.001)] has been evaluated), drawing upon a comprehensive review of the existing literature and leveraging the team’s extensive expertise in the field. The development process included contributions from two clinical pharmacists, one internal medicine specialist, one clinical pharmacy master’s student, and one neuroscientist. DKMQ and PKMQ are calculated on a percentage basis, with higher scores associated with higher levels of knowledge. The questionnaires were administered face-to-face by a clinical pharmacist on days 0 and 90. These tools were utilized to provide comprehensive insight into the sociodemographic characteristics, disease perception, and knowledge levels of patients with prediabetes or diabetes. The data obtained through these questionnaires and scales were analysed to draw meaningful conclusions and recommendations. During the first interview a type III medication review and a structured oral and written patient education was given to participants by clinical pharmacist, lasted approximately 15 min each interview. Type III clinical medication review focuses on issues related to a patient’s use of medicines within the context of their clinical conditions. This review always involves interviewing the patient and includes access to relevant patient information, such as clinical conditions and laboratory test results. It encompasses an evaluation of both medications and health conditions . Patients were provided with brochures specifically developed by the researchers for prediabetes and TIIDM to ensure standardization. The educational materials were developed with consideration for cultural and demographic differences, drawing from current literature to ensure relevance and inclusivity . Patient education included information regarding the disease definitions and types, symptoms, conditions that may occur in the body due to prediabetes and TIIDM, routine tests that should be performed, and risk factors. The aim of these educational sessions was to provide patients with accurate information about their disease and treatment process and to encourage them to take the necessary measures to keep these diseases under control, thus preventing the transition of prediabetes to TIIDM and avoiding complications that may arise from uncontrolled TIIDM. In addition, a reminder telephone interview was performed by the CP at the end of the 1st month, including key points of patient education provided by the CP. At second interview (day 90), in addition to waist circumference measurement and lab values, disease perception and knowledge level questionnaires were readministered by the CP. The questionnaires were used to measure changes in the knowledge levels and perceptions of patients with prediabetes or TIIDM. The primary outcome measures were the change of blood glucose, HbA1c levels, HOMA-IR, serum creatinine, urea, blood urea nitrogen, total cholesterol, LDL and HDL cholesterol levels, waist circumference measurement, complete blood counts, difference on patients’ disease perceptions and knowledge levels of patients about prediabetes and TIIDM.   Demographic data were presented as percentages, while continuous and discrete variables were reported using descriptive statistics such as mean, standard deviation, standard error, median, interquartile range, and mode. The missing data is excluded from the analysis. The significance of assessing patients’ knowledge regarding prediabetes or TIIDM treatment was determined using the Chi-Square or Fisher's exact tests. Changes in routine laboratory measurements, including blood glucose, glycosylated haemoglobin, and HOMA-IR levels, over 90-day intervals were analysed. To investigate the possible association between variables, the Mann–Whitney U and Wilcoxon signed rank tests were employed after assessing the results of the Kolmogorov–Smirnov test. Statistical analysis was performed using SPSS 26.0 and Jamovi software. Statistical significance was indicated by p < 0.05 at a 95% confidence interval.   During the study period, 169 patients meeting the eligibility criteria and applied at the outpatient clinic in a tertiary hospital were invited to participate in this study [missing data ( n = 12), refusal to sign the consent form. ( n = 5), lost follow up ( n = 7)] (Fig. ). Among 145 eligible patients included 66 had prediabetes, whereas 79 was diagnosed with TIIDM. Table provides an overview of the sociodemographic characteristics of the study participants. Prediabetes group According to our results 47 (71.21%) of pDG patients obtained information about their condition from their physicians, 18 (27.27%) from their pharmacists, and 1 (1.52%) from the internet. Prediabetes patients were evaluated at the 1st and 2nd interviews, and the changes in anthropometric measurements (Height, Weight, Waist circumference, Body mass index, blood pressures measurement) and laboratory values used to evaluate the prediabetes (fasting blood glucose level, postprandial blood glucose level, HDL, LDL, HbA1c %, HOMA-IR, eGFR, urea levels etc.) between each interview are given in Table . A Significant decrease were observed among the prediabetes patients’ weight, waist circumference, body mass index, SBP, DBP, fasting blood glucose level, postprandial blood glucose level, LDL, HbA1c %, HOMA-IR, eGFR, urea levels while HDL levels were significantly increased between the interviews ( p < 0.001). The disease perceptions and knowledge of prediabetes patients were assessed using scales in both interviews, and their responses were subsequently compared. There was a statistically significant increased between the interviews in the responses of the prediabetes patients to the illness perception scale ( p < 0.001). The answers of prediabetes patients to the illness perception scale in 1 and 2 interviews are given in Table . The knowledge level of pDG patients regarding prediabetes exhibited a significant change between the interviews ( p < 0.001) (Fig. ). Diabetes group Initially, 60 (75.9%) of the DMG patients received information about their disease from their physicians, 16 (20.3%) from pharmacists, and 3 (3.8%) from the internet. DMG patients were evaluated at the 1st and 2nd interviews, and the changes in anthropometric measurements (Height, Weight, Waist circumference, Body mass index, blood pressures measurement) and laboratory values used to evaluate the prediabetes (fasting blood glucose level, postprandial blood glucose level, HDL, LDL, HbA1c %, HOMA-IR, eGFR, urea levels etc.) between each interview are given in Table . A Significant decrease were observed among the prediabetes patients’ weight, waist circumference, body mass index, SBP, DSP, fasting blood glucose level, postprandial blood glucose level, LDL, HbA1c %, HOMA-IR, eGFR, urea levels while HDL levels were significantly increased between the interviews ( p < 0.001). Disease perceptions and diabetes-related knowledge of the patients were evaluated through scales (IPQ-R and DKMQ) during both interview sessions, and their responses were subsequently compared. A statistically significant increase was observed in the responses of DMG patients to the IPQ-R scale between the two interviews ( p < 0.001). Table presents the responses of diabetes patients to the disease perception scale in the first and second interviews. Furthermore, the knowledge level of patients concerning diabetes demonstrated a significant alteration between the interviews ( p < 0.001) (Fig. ).   According to our results 47 (71.21%) of pDG patients obtained information about their condition from their physicians, 18 (27.27%) from their pharmacists, and 1 (1.52%) from the internet. Prediabetes patients were evaluated at the 1st and 2nd interviews, and the changes in anthropometric measurements (Height, Weight, Waist circumference, Body mass index, blood pressures measurement) and laboratory values used to evaluate the prediabetes (fasting blood glucose level, postprandial blood glucose level, HDL, LDL, HbA1c %, HOMA-IR, eGFR, urea levels etc.) between each interview are given in Table . A Significant decrease were observed among the prediabetes patients’ weight, waist circumference, body mass index, SBP, DBP, fasting blood glucose level, postprandial blood glucose level, LDL, HbA1c %, HOMA-IR, eGFR, urea levels while HDL levels were significantly increased between the interviews ( p < 0.001). The disease perceptions and knowledge of prediabetes patients were assessed using scales in both interviews, and their responses were subsequently compared. There was a statistically significant increased between the interviews in the responses of the prediabetes patients to the illness perception scale ( p < 0.001). The answers of prediabetes patients to the illness perception scale in 1 and 2 interviews are given in Table . The knowledge level of pDG patients regarding prediabetes exhibited a significant change between the interviews ( p < 0.001) (Fig. ).   Initially, 60 (75.9%) of the DMG patients received information about their disease from their physicians, 16 (20.3%) from pharmacists, and 3 (3.8%) from the internet. DMG patients were evaluated at the 1st and 2nd interviews, and the changes in anthropometric measurements (Height, Weight, Waist circumference, Body mass index, blood pressures measurement) and laboratory values used to evaluate the prediabetes (fasting blood glucose level, postprandial blood glucose level, HDL, LDL, HbA1c %, HOMA-IR, eGFR, urea levels etc.) between each interview are given in Table . A Significant decrease were observed among the prediabetes patients’ weight, waist circumference, body mass index, SBP, DSP, fasting blood glucose level, postprandial blood glucose level, LDL, HbA1c %, HOMA-IR, eGFR, urea levels while HDL levels were significantly increased between the interviews ( p < 0.001). Disease perceptions and diabetes-related knowledge of the patients were evaluated through scales (IPQ-R and DKMQ) during both interview sessions, and their responses were subsequently compared. A statistically significant increase was observed in the responses of DMG patients to the IPQ-R scale between the two interviews ( p < 0.001). Table presents the responses of diabetes patients to the disease perception scale in the first and second interviews. Furthermore, the knowledge level of patients concerning diabetes demonstrated a significant alteration between the interviews ( p < 0.001) (Fig. ).   Managing prediabetes and TIIDM presents significant challenges, particularly in diagnosis and follow-up. Nearly half of patients with prediabetes or TIIDM remain undiagnosed, representing an important public health problem. Enhancing patient knowledge and disease perception about these conditions is essential for effective disease management. Our study investigated the impact of CP-led pharmaceutical care services, including medication reviews, patient counselling, education, and follow-up, on disease prognosis, knowledge levels, and perceptions among patients with prediabetes and TIIDM. Consistent with the literature, our findings revealed that such interventions benefit patients, particularly those with poorly managed diabetes (HbA1c > 9%) or insufficient knowledge about their condition. These results highlight the importance of targeting specific patient groups to maximize the benefits of pharmaceutical care services. Numerous studies have highlighted the significant role of CPs in improving glycaemic control among patients with TIIDM. Wubben and Vivian  observed an average HbA1c reduction of 0.62% following CP interventions. Zhang et al.  corroborated these findings in their systematic review and meta-analysis of 35 randomized controlled trials, reporting a mean HbA1c reduction of 0.70%. Similarly, Aguiar et al.  demonstrated a reduction of 0.85% in HbA1c levels, particularly effective for patients with baseline HbA1c > 9% . In the current study, we observed an average reduction in HbA1c levels of 0.67% among patients during their first and second visits, aligning closely with the aforementioned results. This consistency underlines the substantial impact of CP-led interventions, including patient education, medication reviews, and lifestyle counselling, on achieving better glycaemic control. The observed reduction in fasting blood glucose levels in our study, further supports the effectiveness of CP-led strategies. This outcome is consistent with Collins et al. , who reported a mean fasting blood glucose reduction of 1.63 mmol/L in their intervention group. These reductions are indicative of improved metabolic parameters, which are critical in preventing the long-term complications of diabetes, such as nephropathy, retinopathy, and cardiovascular disease . Moreover, CPs’ interventions have been shown to contribute to individualised patient care by closely monitoring glycaemic parameters and adjusting treatment plans in collaboration with other healthcare professionals. This collaborative approach not only optimises clinical outcomes but also enhances patient satisfaction and trust in the healthcare system. Improved disease perception and knowledge are critical for effective diabetes management, and CPs play a pivotal role in these domains. Studies have demonstrated that CP-led educational interventions enhance patients’ understanding of their condition and treatment options. For example, Hughes et al.  noted significant improvements in patients’ knowledge about disease complications, treatment modalities, and self-monitoring. These educational strategies positively influence patients’ perception of their disease, fostering a proactive approach to self-management. Our study observed similar outcomes, with notable advancements in patient knowledge regarding diabetes management. The increased awareness likely contributed to improved adherence to treatment plans and better glycaemic outcomes. CPs’ ability to provide personalised education sessions, coupled with the use of visual aids and practical demonstrations, enables patients to comprehend complex medical information effectively. This tailored approach ensures that patients are well-equipped to make informed decisions about their care. Furthermore, by addressing misconceptions and providing continuous support, CPs empower patients to take ownership of their health, thereby facilitating sustainable behavioural changes essential for long-term diabetes control. Adherence to treatment regimens is a critical determinant of diabetes outcomes. The systematic review by Presley et al.  highlighted that CP interventions, such as medication reviews, regular follow-ups, and the provision of printed or digital educational materials, significantly enhance adherence rates. Blenkinsopp and Hassey  also emphasised the effectiveness of CP-driven interventions in improving adherence, as demonstrated in six out of seven studies reviewed. Furthermore, Hughes et al.  reported improved adherence through pharmacist-led initiatives, although the direct impact on clinical outcomes varied. In our study, adherence-related improvements were evident, likely facilitated by CP-led education and regular monitoring. These findings align with evidence suggesting that targeted CP interventions can bridge gaps in adherence, thereby optimising diabetes management. Specific strategies employed by CPs in this context include identifying barriers to adherence, such as complex medication regimens or side effects, and developing tailored solutions to overcome these challenges. For example, simplifying dosing schedules, implementing reminder systems, and conducting motivational interviews have proven effective in enhancing adherence. The provision of ongoing support, including follow-up consultations and access to CPs for queries, further reinforces adherence behaviours and strengthens the patient-pharmacist relationship. Strength and limitations This study is subject to several limitations. Although the targeted number of patients was achieved, the generalizability of the findings is constrained by the relatively small sample size. Additionally, conducting the study during the Covid-19 pandemic within a limited timeframe, posed other challenges. The variability in patient profiles due to the pandemic further constrained the sample size. Furthermore, the study solely relied on clinical data, such as routine laboratory results, and patient education was not repeated, occurring only one month after the first visit. The findings demonstrate the positive impact of clinical pharmacists on patients with prediabetes or diabetes, employing a multidisciplinary approach consistent with literature.   This study is subject to several limitations. Although the targeted number of patients was achieved, the generalizability of the findings is constrained by the relatively small sample size. Additionally, conducting the study during the Covid-19 pandemic within a limited timeframe, posed other challenges. The variability in patient profiles due to the pandemic further constrained the sample size. Furthermore, the study solely relied on clinical data, such as routine laboratory results, and patient education was not repeated, occurring only one month after the first visit. The findings demonstrate the positive impact of clinical pharmacists on patients with prediabetes or diabetes, employing a multidisciplinary approach consistent with literature.   There is considerable evidence to support the role of CP in providing a range of extended prediabetes and TIIDM care services, from disease screening through to ongoing disease state management. However, the provision of such services often remains limited and unstandardized. This will change as the number of people with prediabetes and TIIDM increases, and the follow-up capacity of traditional care providers diminishes. Clinical pharmacists are ideally placed to assist patients with the management of prediabetes and TIIDM in a range of clinical settings, as current evidence shows.   Supplementary Material 1. Supplementary Material 2.   