An overview of the amount of awareness of clinical data surrounding the prescribing and utilization of GLP-1 agonists for the treatment of patients with type 2 diabetes versus other treatment options.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: I have a question for you ladies. I sit in an endocrine clinic, so on the diabetes continuum where I’m inheriting the patients. I know we all know some of this data that we’re talking through today. Do you find that your clinicians know this piece of data? Because here’s an example that happened for us starting the new year: We switched our formulary DPP-4 [dipeptidyl-peptidase-4] inhibitor. So we all got a list of patients who needed to be converted. Our endocrine team consists of 3 endocrinologists, a nurse practitioner, and me, and we take consults from all of our primary care folks. Between the 5 of us, we had 19 prescriptions for a DPP-4 inhibitor that needed to be converted to a GLP [glucagon-like peptide], because that’s how much we use GLP. So I’m curious to see if this is similar where you guys are practicing? We know that the data are there with the GLPs. Do you see the follow through?
Jessica L. Kerr, PharmD, CDE: I really do think it comes down to where you are practicing. If you are working in a community pharmacy, sometimes you don’t have those collaborations with some of the other clinicians that are actually prescribing. In my situation, I serve as a provider within the VA [US Department of Veterans Affairs], but I have primary care doctors for whom I still have to go in and do routine education on this and explain why. I’m also able to help them construct a most appropriate reason as to why 1 individual patient needs this particular therapy. If the patient doesn’t have a cardiovascular indication at this point, it might be hard to state that a GLP-1 or an SGLT2 [sodium-glucose cotransporter 2] is definitely needed when the patient is of normal weight and everything else. We know those positive benefits of those new classes, but at some point, you also have to be responsible with where the health system and finance system is as well. I think if we have extra services within a primary care setting or even in a community setting, I think it works that way. But otherwise, it can be difficult.
Troy Trygstad, PharmD, MBA, PhD: Do you see a difference in prescribing patterns between your primary care doctors and your endocrinologists?
Susan Cornell, PharmD, CDE, FAPhA, FAADE: I actually do. My situation is very different. I work in a free clinic, so often what is prescribed is whatever we have in the closet or the refrigerator. And that might change month to month, or every 3 months. What I can say is that when working with the nurse practitioners, the PAs [physician assistants], the primary care that I work with, I do need to spend a little bit more time on the education part and the guidelines. So, for example, just a few weeks ago, our nurse practitioner didn’t even realize the guidelines had changed. Even from the mindset of, “What are we going to prescribe, and what’s the reason I’m going with the GLP-1 now opposed to the DPP-4,” it’s partially about getting her to understand the guidelines. The endocrinologists, and we have very few of them in the free clinic and it’s hard to get an appointment, are of course more on board because they’re kind of up to speed on this.
I think one of the most interesting things is there’s a clinical inertia or there’s a clinical presumption by some prescribers. So one of the challenges I face is that my prescribers don’t like to use a GLP-1 because they assume the patient will not want an injection. They make that assumption without even talking to the patient. And then we have a conversation with the patient, myself, as the pharmacist and diabetes educator, and the patient says, “I don’t mind an injection, especially if it’s related to weight loss. Sign me up.” I have no resistance. But it’s this presumption that, “Oh, they’re not going to want that.”
Troy Trygstad, PharmD, MBA, PhD: Some patients believe injections are more effective, for whatever reason, because they’re injections, right?
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: I would echo the same thing. I think the weight loss piece that comes with this drug class—and then in some cases, you have your twice-a-day, once-a-day, to then almost once-weekly now—is that they’re like, “Yeah, I’m going to lose weight and I only have to do this once a week.” Usually that resistance isn’t there like we first thought or have seen, and have also thought about it when we were talking about a basal bolus where you might have to be checking levels a lot more, having 4 injections a day. It’s not that complex. And so, the patient buy-in is there, but I think it’s that historical, “It’s an injectable, the patient is not going to want it.” But then when given the option of something that’s going to cause weight gain versus something that’s going to help them to lose weight, and in addition to that, it helps with all these other things—it’s usually something that they’re OK doing.