What is Guideline-Directed Care?
MCT2D aims to align medication prescribing with guideline directed care.
Interventions that focus on prescribing in accordance with standards of care as defined by the American Diabetes Association such as the deprescribing of insulin and appropriate prescribing of medications such as GLP-1RAs and SGLT2is based on patient comorbidities like chronic kidney disease, heart failure and/or prior history of heart disease. It also involves ensuring patient-centered treatment selection and substitution of alternative medication if guideline directed treatments are unaffordable or not covered by insurance.
Why Deprescribing of Insulin and Older Diabetes Medications?
Deprescribing is the process of stopping medications in order to improve patient outcomes or reduce polypharmacy.
Older antihyperglycemic medications such as sulfonylureas, dipeptidyl peptidase-4(DPP4i), and insulin have been shown in clinical trials to be less effective at controlling blood sugar and to provide little protection or treatment for the cardiorenal complications of diabetes. Insulin and sulfonylureas also increase the risk of hypoglycemia and are more likely to be associated with weight gain and further progression of diabetes complications.
Deprescribing of these medications is appropriate for patients whose blood sugar is at goal, those who are at higher risk of hypoglycemia, and those who would benefit from treatments to treat or prevent diabetes complications and comorbidities like chronic kidney disease, heart failure and atherosclerotic cardiovascular disease (heart attack and stroke). These patients may benefit from selecting other medications that improve patient outcomes, also known as “guideline directed medical therapy (GDMT)
What is Medication Compliance and How Does it Relate to Guideline Directed Medical Therapy and Deprescribing?
Newer, more effective classes of diabetes medications may be unaffordable due to lack of insurance coverage, high copayments and out of pocket costs. Medication adherence to antihyperglycemic medication is measured by Medicare and other payors to make sure patients are able to afford and take their medications. Clinicians can inquire and understand any hardships that are getting in the way of patients adhering to these newer medications, and prescribing an alternative medication to treat hyperglycemia.
This alternative medication would ideally be a different medication in the same class that may be better covered (preferred status) by insurance. In cases where a patient does not have insurance or is unable to afford their insurance’s co-pay, an affordable alternative class of medication, such as metformin, a sulfonylurea, a DPP-I or insulin can be considered to avoid a lapse in treatment for hyperglycemia.
Appropriate prescribing of GLP-1 Receptor Agonists & SGLT2 inhibitors
These classes of medications improve glucose control, decrease mortality and adverse cardiovascular events, slow chronic kidney disease progression and support weight loss.
What Are Sodium Glucose Cotransporter-2 Inhibitors (SGLT2i)?
SGLT2is are a class of glucose-lowering drugs that prevent reabsorption of blood glucose filtered by the kidneys, leading to glucose excretion in the urine. SGLT2is have added benefits for patients with heart failure, atherosclerotic cardiovascular disease, and chronic kidney disease. SGLT2is can also facilitate weight loss.
What Are Glucagon-like Peptide-1 Receptor Agonists (GLP-1 RAs)?
GLP-1 RAs are a class of glucose-lowering drugs that work by stimulating the release of insulin by the pancreas in response to eating, reducing appetite, and increasing fullness after a meal by slowing gastric emptying. GLP-1 RAs have added benefits for patients with cardiovascular disease, chronic kidney disease, and facilitating weight loss for patients with type 2 diabetes and overweight or obesity.
Why SGLT2is and GLP-1 RAs?
Scientific studies demonstrate the benefit of these two classes of medications in reducing cardiovascular and renal complications for patients with type 2 diabetes. While historically, clinicians prescribed medications only for glucose lowering, now the American Diabetes Association Standards of Care recommend therapy directed at preventing complications, controlling blood sugar and helping people achieve weight loss to improve outcomes in type 2 diabetes.
Evidence is changing rapidly with regards to first-line and second-line medications for the treatment of hyperglycemia in type 2 diabetes. SGLT2is and GLP-1RAs are now first-line medications for patients at high risk of cardiovascular and renal complications and those with obesity. Many barriers exist to implementation of this evidence into primary care practices, including cost of medications, knowledge among primary care physicians, and patient education.