Adjunctive therapy for T1D: What drives prescribing?

Type 1 diabetes

By Geir O'Rourke

24 Jan 2024

Australian endocrinologists are regularly prescribing adjunctive therapy to treat T1D, despite concerns over DKA risk and off-label status, research has shown.

Based on survey data, the study highlights the need for better evidence into the use of adjuncts in T1D treatment, particularly around their safety, the investigators say.

Some 52 endocrinologists and registrars, mostly from metropolitan Sydney, answered the online poll, with 94% reporting that they had prescribed adjuncts for T1D treatment in some form.

Most commonly prescribed were metformin (94%) and SGLT-2 inhibitors (65%), while 60% said they had prescribed a GLP-1RA at least once.

Interestingly, the most common reason given for prescribing adjunctive therapy was patient weight, reported by 89% of those who had done so, the researchers said.

Other popular motivators were large insulin doses (73%), glycaemic variability (52%), high HbA1c (48%) and the presence of cardiovascular disease (48%), they reported.

“This mirrors the real-world benefits of GLP-1RA and SGLT-2 inhibitors inT1DM and prescribing patterns of US-based physicians,” they wrote in IMJ (link here).

The authors added: “Observational studies of patients with T1DM have shown an increasing number of overweight and obese individuals, in keeping with general population trends.”

“This increasing prevalence of overweight and obesity results in the need for higher doses of insulin, which promotes further weight gain and insulin resistance and increases cardiovascular risk.”

Nevertheless, many respondents had some trepidation about adjunctive therapy, with DKA risk a universally-reported factor among all those who had never prescribed an SGLT2i or GLP-1RA.

Significant numbers also cited lacking evidence and off-label status as a concern, pointing to the need for more research, the authors said.

On the other hand, cost did not appear to be a frequent barrier, cited by only a minority of those doctors who did not prescribe such therapy.

“This may be a reflection of location of practice, with the majority of respondents working in metropolitan areas,” the authors noted.

“There was no difference in prescribing patterns between endocrinologists and endocrinology registrars.”


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