Abstract
The disclosure of proven cardiorenal benefits with certain antidiabetic agents was supposed to herald a new era in the management of type 2 diabetes (T2D), especially for the many patients with T2D who are at high risk for cardiovascular and renal events. However, as the evidence in favour of various sodium–glucose transporter-2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) accumulates, prescriptions of these agents continue to stagnate, even among eligible, at-risk patients. By contrast, dipeptidyl peptidase-4 inhibitors (DPP-4i) DPP-4i remain more widely used than SGLT2i and GLP-1 RA in these patients, despite a similar cost to SGLT2i and a large body of evidence showing no clear benefit on cardiorenal outcomes. We are a group of diabetologists united by a shared concern that clinical inertia is preventing these patients from receiving life-saving treatments, as well as placing them at greater risk of hospitalisation for heart failure and progression of renal disease. We propose a manifesto for change, in order to increase uptake of SGLT2i and GLP-1 RA in appropriate patients as a matter of urgency, especially those who could be readily switched from an agent without proven cardiorenal benefit. Central to our manifesto is a shift from linear treatment algorithms based on HbA1c target setting to parallel, independent considerations of atherosclerotic cardiovascular disease, heart failure and renal risks, in accordance with newly updated guidelines. Finally, we call upon all colleagues to play their part in implementing our manifesto at a local level, ensuring that patients do not pay a heavy price for continued clinical inertia in T2D.
Highlights
It has been 5 years since we first learned that empagliflozin can save lives and substantially reduce cardiovascular (CV) risk in patients with type 2 diabetes (T2D) and CV disease (CVD) [1]
We find that low uptake of sodium–glucose transporter-2 inhibitor (SGLT2i) and GLP-1 Glucagon-like peptide-1 receptor agonist (RA) cannot be primarily explained by pharmacy cost differences, as shown by comparisons with dipeptidyl peptidase-4 inhibitors (DPP-4i), but instead forms part of a broader picture of clinical inertia in the management of T2D that affects HbA1c targets
In our ‘manifesto for change’, we offer practical suggestions on how to start to dismantle the barriers standing in the way of SGLT2i and GLP-1 RA, and call for all clinicians involved in the care of patients with T2D to play their part in this mission
Summary
It has been 5 years since we first learned that empagliflozin can save lives and substantially reduce cardiovascular (CV) risk in patients with type 2 diabetes (T2D) and CV disease (CVD) [1]. The majority of eligible patients still do not receive agents for which protective effects have been proven [26,27,28,29,30], presenting an urgent need to increase uptake of SGLT2i and GLP-1 RA as part of the standard of care for managing cardiorenal risk in patients with T2D [10].
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