The Reasons for the Low Uptake of New Antidiabetic Drugs with Cardiovascular Effects-A Family Doctor Perspective

Abstract

Chronic diseases, such as type 2 diabetes (T2D), are difficult to manage because they demand continuous therapeutic review and monitoring. Beyond achieving the target HbA1c, new guidelines for the therapy of T2D have been introduced with the new groups of antidiabetics, glucagon-like peptide-1 receptor agonists (GLP-1ra) and sodium-glucose cotransporter-2 inhibitors (SGLT2-in). Despite new guidelines, clinical inertia, which can be caused by physicians, patients or the healthcare system, results in T2D not being effectively managed. This opinion paper explores the shift in T2D treatment, challenging assumptions and evidence-based recommendations, particularly for family physicians, considering the patient's overall situation in decision-making. We looked for the possible reasons for clinical inertia and the poor application of guidelines in the management of T2D. Guidelines for antidiabetic drugs should be more precise, providing case studies and clinical examples to define clinical contexts and contraindications. Knowledge communication can improve confidence and should include clear statements on areas of decision-making not supported by evidence. Precision medicine initiatives in diabetes aim to identify subcategories of T2D patients (including frail patients) using clustering techniques from data science applications, focusing on CV and poor treatment outcomes. Clear, unconditional recommendations for personalized T2D management may encourage drug prescription, especially for family physicians dealing with diverse patient contexts and clinical settings.

Keywords: clinical guidelines; glucagon-like peptide-1 receptor agonists; primary healthcare; sodium-glucose cotransporter-2 inhibitors; therapeutic inertia; type 2 diabetes.

Figure 1

The overlap rates among the eligible patients for treatment with GLP-1ra or SGLT2inh. The unpublished results from our research that is cited in refs. [32,33] (N = 170, F:M = 95:75, age 50–89 years, median 66). The simplified criteria for prescribing GLP-1ra or SGLT2inh: C1: Atherosclerotic CVD (Coronary artery disease, Periphery artery disease or Cerebrovascular disease); C2: Age ≥ 55 years + chronic heart disease; C3: estimated glomerular filtration rate ((eGFR) < 60 mL/min).

Figure 2

Distribution of patients that have T2D and are diagnosed with CVD (red: no CAD or CHD; blue: both CAD and CHD; green: only CHD; violet: only CAD) according to frailty status (A: nonfrail, B: pre-frail, C: frail); Fisher Test p-value (0.003). The results from our research (N = 170, F:M = 95:75, age 50–89 years, median 66). The results from our research that is cited in ref. [33].

Figure 3

Sex-dependent distribution (blue: men, red: women) of patients with T2D according to their frailty status (A: nonfrail, B: pre-frail, C: frail); Pearson Chi-Square (p-value = 0.02). The results from our research (N = 170, F:M = 95:75, age 50–89 years, median 66). The results from our research that is cited in ref. [33].