Permission to prescribe: do cardiologists need permission to prescribe diabetes medications that afford cardiovascular benefit?

Abstract

Purpose of reviewAntihyperglycemic therapies including sodium glucose contransporter-2 inhibitors (SGLT2i) and glucagonlike peptide-1 receptor agonists (GLP-1 RA) have been demonstrated to confer significant cardiovascular benefit and reduce future events in patients with type 2 diabetes mellitus (T2DM). However, despite positive data from cardiovascular outcome trials, these therapies remain underutilized in a large proportion of patients who have clinical indications and meet coverage guidelines for their initiation. One of the causes of the observed gap between scientific evidence and clinical cardiology practice is therapeutic hesitancy (otherwise known as therapeutic inertia). The purpose of this review is to discuss the contributors to therapeutic hesitancy in the implementation of these evidence-based therapies and, more importantly, provide pragmatic solutions to address these barriers. Recent findingsRecent studies have demonstrated that clinicians may not initiate cardiovascular protective therapies due to a reluctance to overstep perceived interdisciplinary boundaries, concerns about causing harm due to medication side effects, and a sense of unfamiliarity with the optimal choice of therapy amidst a rapidly evolving landscape of T2DM therapies. SummaryHerein, we describe a multifaceted approach aimed at creating a 'permission to prescribe' culture, developing integrated multidisciplinary models of care, enhancing trainees' experiences in cardiovascular disease prevention, and utilizing technology to motivate change. Taken together, these interventions should increase the implementation of evidence-based therapies and improve the quality of life and cardiovascular outcomes of individuals with T2DM.

County-level variation in cardioprotective antihyperglycemic prescribing among medicare beneficiaries

“…Additionally, while we used metformin prescriptions as a surrogate for patients being actively managed for type 2 diabetes, the use of metformin for other indications, including prediabetes and polycystic ovarian syndrome, may be reflected in modest reductions in the observed use of SGLT2i and GLP1-RA as compared to metformin. However, the vast majority of metformin use is for patients with established type 2 diabetes as less than 1% of those with prediabetes are prescribed metformin and it is no longer strongly recommended for polycystic ovarian syndrome, and is therefore, unlikely to substantially affect our observations [ 37 , [1] , [2] , [3] , [4] , [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] ]. Finally, identifying counties based on city and state is slightly imprecise given variations in how administrative divisions are defined (e.g.…”

(Optimizing Foundational Therapies in Patients With HFrEF. How Do We Translate These Findings Into Clinical Care? Translation of the document prepared by the Czech Society of Cardiology)

“…22 Uvedená nerozhodnost a váhavost byla ostatně pozorována i při zavádění nových antidiabetik u pacientů s diabetem 2. typu (T2DM) a s prokázaným aterosklerotickým kardiovaskulárním onemocněním. 23 Jedná se o nesmírně důležitou otázku, protože: 1) optimální léčby se nedostává vysokému procentu vhodných pacientů, a 2) pokud se již u nich provádí, zahájení léčby se často dlouho odkládá. Souhrnné údaje ze studií ukazují, že přínos optimální léčby se již brzy po jejím zahájení zvyšuje; proto neprovádění optimální léčby, nebo dokonce její oddalování vystavuje pacienty riziku, které lze potenciálně odvrátit.…”

Utilizing type 2 diabetes medications outside glycemic parameters – where are we headed?

“…Although there is strong evidence to initiate these medications in both diabetes and nondiabetes populations, there is therapeutic inertia among nonendocrine providers [28 ▪ ]. A global prospective observational study known as DISCOVER, followed >14 000 patients with type 2 diabetes from 37 countries over 3 years [29].…”

“…They found that 1579 patients (10.8%) were started on an SGLT-2i (1275; 8.7%) or GLP-1 RA (318; 2.2%) at enrollment, increasing to 2348 patients (16.1%) for either agent (1870 [12.8%] SGLT-2i only, 376 [2.6%] GLP-1 RA only, 102 [0.7%] both agents) at the end of the study [29].Although the use increased over time, it was still suboptimal for the desired population. Barriers to prescribing these cardioprotective agents include reluctance to overstep interdisciplinary boundaries, medication side effects, unfamiliarity, and discomfort with choosing the correct agent in the evolving type 2 diabetes pharmacotherapeutic field [28 ▪ ].…”