Type 2 diabetes

Endocrinologist education sought by GPs on complex T2D therapy choices

GPs want more education from endocrinologists on the use of T2D therapies such as SGLT2 inhibitors, but finding the time and getting the format right appears to be a challenge for all parties.

A study into why GPs are reluctant to take advantage of the extra-glycaemic benefits of SGLT2 inhibitors in type 2 diabetes has found that they are often confused by the multitude of agents available for type 2 diabetes and prefer to leave decisions to endocrinologists rather than try decipher complex guidelines and treatment algorithms.

In a series of interviews with 15 GPs and 12 endocrinologists in NSW, researchers at Sydney University investigating the barriers to SGLT2 inhibitor usage identified a key theme of under-appreciation of their cardio-renal benefits by GPs and a preference for an endocrinologist to initiate therapy.

And rather than PBS restrictions based on HbA1c level for subsidy of SGLT2 inhibitors, GPs were more likely to cite the complexity of second and third line therapeutic options for type 2 diabetes as a barrier to initiation of the agents.

With several different drug classes such as GLP-1 receptor agonists and DPP-4 inhibitors and with each class generally comprising a few agents, GPs expressed caution about the different properties of the various agents and difficulty in trying to individualise pharmacotherapy based on the comorbidities or risk factors of an individual patient.

“I do find myself referring more to an endocrinologist. I find there’s so many agents out there,” one participant told the investigators.

GPs reported seeking information from the NPS MedicineWise website and journals, but many were not aware of the Australian Type 2 Diabetes Management Algorithm published by the Australian Diabetes Society (ADS), or spoke of difficulties engaging with this type of information.

“I do tend to find flowcharts and guidelines incredibly boring to scan. You know, I find it much easier if someone gives you a half-hour talk on what they do and why,” said one.

Endocrinologist input

When discussing preferred methods of education about type 2 diabetes pharmacotherapy, many GPs said they valued the input of endocrinologists and spoke of learning from the prescribing habits of endocrinologists.

Many GPs expressed a preference for endocrinologist-led sessions based on patient cases and interactive, preferably independent of pharmaceutical company sponsorship.

The endocrinologists interviewed said they would like to offer more such educational sessions for GPs but faced competing demands on their time as they had to provide training in other areas of endocrinology beyond diabetes and provide education to physician trainees and medical students.

Some endocrinologists also said they felt constrained by education events being sponsored by pharmaceutical companies where the focus was on one agent, whereas they wanted to discuss all the available therapy options.

“They (the pharmaceutical company) were using really case histories that felt plastic to me, and the whole point was to, you know, use X (referring to a certain drug), use X… But these GPs are going to want to hear how these new drugs fit in, and I’m not doing this talk unless I’m allowed to,” said one endocrinologist.

But the endocrinologists interviewed said they agreed that the most useful educational format would be interactive and based on patient cases.

“I find that’s often what GPs want to do at these things, they’ll say “I have this one patient who, how would I handle this?”… they often want to bring it back to a specific patient that they have or, you know, something specific to their scenarios,” said one.

The study investigators said their interviews highlighted the need for alternative means of education on SGLT2 inhibitors in T2D and greater engagement with endocrinologists to maximise the support of GPs who may find the area complex and confusing.

They suggested that the widespread adoption of telehealth and videoconferencing during the COVID-19 pandemic could be a model to provide more independent educational engagement between endocrinologists and GPs.

“Given the increasing use of online forums due to the COVID-19 pandemic, such discussion could occur virtually, which has the advantages compared with face-to-face meetings of not requiring financial (and therefore industry) sponsorship and being more accessible to clinicians working in regional and remote areas,” they said.

“Thus, virtual technology potentially offers more cost-effective solutions with greater reach compared with in-person dinners or other events.

“Online forums can occur at a local level with an endocrinologist and a small number of GPs, as well at a regional or national level through organisation by primary health networks/alliances or specialist colleges and societies (increasingly occurring due to the COVID-19 pandemic). Again, given the views of participants, events hosted by these professional organisations should preferably be free of pharmaceutical industry influence and be for purely educational purposes,” they concluded.

The findings are published in Diabetes Research and Clinical Practice.

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