In an interview with Pharmacy Times, Dave Dixon, PharmD, FACC, FAHA, FCCP, FNLA, BCACP, CLS, the Nancy and Ronald McFarlane Professor of Pharmacy and chair of the Department of Pharmacotherapy & Outcomes Science at Virginia Commonwealth University School of Pharmacy, addressed the persistent gap between guideline recommendations and real-world prescribing of sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists and outlined the evolving role of pharmacists in integrated cardio-kidney-metabolic care. Dixon identified therapeutic inertia—at both the clinician and system levels—as the primary driver of underutilization, compounded by specialty silos, cost, prior authorization burden, formulary barriers, and patient hesitancy around side effects.
Dixon argued that pharmacists are uniquely positioned to bridge the gap between evidence and implementation by identifying eligible patients, supporting medication access, and providing proactive education on adverse effects and adherence. Dixon also discussed how the cardio-kidney-metabolic paradigm demands that pharmacists move beyond A1C-centric thinking to assess full cardiorenal risk profiles, including atherosclerotic cardiovascular disease history, heart failure risk, kidney function, urine albumin-to-creatinine ratios, blood pressure, and low-density lipoprotein (LDL). He acknowledged that while ambulatory care pharmacists in team-based models are largely keeping pace, community and health-system pharmacy infrastructure—including collaborative practice agreements, lab access, documentation, and reimbursement—must continue to evolve to fully support this expanded role.
Pharmacy Times: Can you please introduce yourself?
Dave Dixon, PharmD, FACC, FAHA, FCCP, FNLA, BCACP, CLS: My name is Dave Dixon, professor and chair of the Department of Pharmacotherapy and Outcomes Science at Virginia Commonwealth University School of Pharmacy.
Pharmacy Times: Your research has examined prescribing patterns of SGLT2 inhibitors and GLP-1 receptor agonists in cardiology, endocrinology, and primary care settings and found uptake remains poor despite the proven cardiorenal benefits. What are the most significant barriers driving that gap, and where are pharmacists best positioned to intervene?
Dixon: The biggest barrier undoubtedly is therapeutic inertia, but it's not just clinician inertia—where there's an opportunity to optimize care that's just not happening—it's also system inertia. So, thinking about our systems-of-care barriers related to access to care and access to medications. These medication classes often fall between specialties, also: cardiology may view them as more cardiovascular drugs nowadays; primary care has many competing priorities to manage; endocrinologists are generally more focused on improving glycemic control; and nephrologists are typically brought into the care of these patients at a later stage of the disease course. So, despite the strong evidence, patients can go years potentially without being started on these therapies.
There are also practical barriers that we can't ignore: cost, the labor that goes into managing prior authorizations, formulary challenges, concerns about side effects—thinking about patients who are hesitant about injectable therapies or the potential gastrointestinal side effects of GLP-1s is a concern, and while these are generally manageable, they need to be discussed proactively.
I think it's an opportunity where pharmacists are best positioned at the point where the evidence meets implementation. Pharmacists can help with identifying eligible patients, closing gaps related to medication access, supporting prior authorization, providing education to patients and clinicians on adverse effects and how to navigate those, and medication adherence—and so in many cases I think the pharmacist is the person who can really help convert the guideline recommendations into actual implementation: the prescription that the patient can obtain, understand, and stick with long term.
Key Takeaways
- Therapeutic inertia at both the clinician and system level remains the leading barrier to SGLT2 inhibitor and GLP-1 receptor agonist uptake, and pharmacists are best positioned to intervene at the critical junction where guideline evidence meets real-world implementation.
- The cardio-kidney-metabolic model requires pharmacists to assess the full cardiorenal risk profile—including ASCVD history, heart failure risk, kidney function, and LDL—rather than focusing on A1C alone as the primary measure of treatment success.
- A controlled A1C should not be the endpoint: Dixon's single most actionable takeaway for pharmacists is to continue assessing cardiovascular and kidney risk and implementing evidence-based therapies even when glycemic goals have been met.
Pharmacy Times: The 2026 standards reflect a broader shift toward integrated cardio-kidney-metabolic care. How does that paradigm change the clinical role pharmacists are expected to play on the care team, and are current pharmacy practice models keeping pace?
Dixon: I would say the cardio-kidney-metabolic model really changes the pharmacist's role by requiring us to stop thinking in silos. Again, many of our diabetes medications are no longer just diabetes medications—they have cardiovascular and kidney protective benefits. Pharmacists need to be more comfortable thinking about the full risk profile: thinking about A1C but also thinking about atherosclerotic cardiovascular disease (ASCVD) history; the risk of developing heart failure—which patients with diabetes experience at a higher rate compared to those without diabetes—assessing kidney function; making sure that urine albumin-to-creatinine ratios are checked, which is often a big gap; blood pressure control; and LDL management. Really, the question is not simply, "Is the patient at their A1C goal?" It's much broader—is this patient receiving the preventive therapies most likely to reduce cardiovascular and kidney events?
From a pharmacy practice model perspective, I would say that we're partially keeping pace, but not consistently. Certainly, ambulatory care pharmacists are often practicing this way, particularly in team-based models, whether that's in the primary care office or a specialty clinic. But in community pharmacy and many health-system workflows, we need better infrastructure: access to lab results; the opportunity to engage in collaborative practice agreements or expand scope of practice to allow pharmacists to initiate and modify these drug therapies; and referral pathways—how do patients that could benefit from pharmacy services get to a pharmacist, and how is that care documented in a system that can be seen by the entire team? And then ultimately it comes down to a reimbursement model that can support this effort to provide longitudinal risk management rather than a one-time medication review. So the opportunity is enormous, but I do think that the model to support pharmacists at the top of their training is still evolving, and we still have work to do.
Pharmacy Times: For pharmacists attending your symposium who work in community, ambulatory care, or health-system settings, what is the single most actionable takeaway you want them to leave with when it comes to cardiovascular risk management in patients with diabetes?
Dixon: I would say that the single most actionable takeaway is don’t let a controlled A1C stop you from assessing cardiovascular and kidney risk and implementing these evidence-based therapies to further reduce that risk. I think that that's been happening for some time, but with the more recent evidence—especially in terms of improving outcomes in patients with heart failure who have diabetes, as well as improving kidney outcomes—we really have to double down on our efforts. And I think, to me, that's where, again, pharmacists just have a tremendous opportunity. It changes that conversation away from simple glucose management to thinking about event prevention, which is ultimately what we want for our patients—and I think our patients want that outcome as well.
