Keywords: Type 2 diabetes, Cardiovascular risk, SGLT2ins, GLP-1RAs, Therapeutic inertia, Family medicine, Diabetology

Background:

Type 2 diabetes (T2D) treatment has undergone major changes in the last decades. Earlier glucocentric approach was advanced to more comprehensive strategy of simultaneous monitoring of glycemia and cardiovascular (CV) risk. This approach was enabled by introducing novel medications into practice, SGLT2ins and GLP-1RAs. Despite proven beneficial CV effects, worldwide research indicates their low prescription, commonly attributed to therapeutic inertia.

Research questions:

What is the prescribing practice and attitudes of Croatian general practitioners (GPs) towards novel antidiabetic medications and which factors influence their self-confidence in the prescribing?

Method:

This cross-sectional study examined 218 GPs (10% of the total GP population in Croatia) using an anonymous, self-designed questionnaire, delivered via e-addresses of the practices. Both open- and closed-ended questions were included, and some used a 5-point Likert scale. Exact data on the respondents' and patients' characteristics were obtained from the e-health records. The assessment of the influence of inertia factors on the probability of lower self-confidence was done using bivariate and multivariate logistic regression.

Results:

A total number of 30,660 (8.7%) individuals with T2D under the care of respondent GPs participated in the study. Of them, nearly 60% were treated solely in primary care without referral to a diabetologist. The same proportion had at least one associated CV comorbidity and only half had well-regulated hemoglobin A1c. SGLT2ins were prescribed in 21.4%, GLP-1RAs in 14.8% and both medications in 7.6% of patients. Around 75% and 55% of GPs declared high self-confidence for autonomous prescription of SGLT2ins and GLP-1RAs respectively. The most prominent predictor of lower self-confidence was lack of knowledge or clarity of guidelines, while one that could support their confidence was familiarity with medication's side effects.

Conclusions:

Identification of barriers that GPs encounter while prescribing novel antidiabetic medications is of the utmost importance for suggesting the strategies for mitigation of therapeutic inertia and T2D treatment optimization.

Points for discussion:

Should SGLT2ins and GLP-1RAs be autonomously prescribed by GPs for individuals with T2D?

Is CV risk sufficiently and timely assessed in individuals with T2D?

Which methods for improving the quality of care for T2D individuals should be implemented?