Type 2 Diabetes Prescriptions by GPs Up 33% in UK

Over the past 5 years, the number of prescriptions written for type 2 diabetes medications in England by GPs has risen by 33% — from 26 million to 35 million — according to new figures from data company Exasol.

Overall, for the 5 years, more than half of the prescriptions (52%) were for metformin, widely regarded as first-line therapy for type 2 diabetes worldwide.

And almost a quarter were still for sulfonylureas, mostly gliclazide — 21% of the GP prescriptions were written for this latter agent, indicating that these older drugs are still widely used as second-line therapy.

This is in line with the latest NICE guidance for type 2 diabetes, which was criticized last year but has since been somewhat modified. Initially, the UK drugs watchdog recommended sulfonylureas for use when metformin is no longer sufficient. But then it amended its final guidance to state that doctors could now choose between sulfonylureas, pioglitazone, and newer agents such as dipeptidyl peptidase 4 (DPP-4) inhibitors and sodium-glucose cotransporter 2 (SGLT2) inhibitors as second-line therapy.

And these latest figures (SEE THE 1ST ATTACHMENT) — which capture every GP prescription dispensed in England from August 2010 to December 2015 — show that these newer agents are now being used.

There was a doubling of prescriptions for the DPP-4 inhibitor sitagliptin (Januvia, Merck), for example — from over 96,000 to more than 192,000 in the 5 years, and overall sitagliptin accounted for 6% of prescriptions, indicating greater use of at least two drugs to treat type 2 diabetes.

Another DPP-4 inhibitor, linagliptin (Tradjenta, Boehringer Ingelheim), accounted for 2% of prescriptions, while 5% were for the SGLT2 inhibitor dapagliflozin (Forxiga/Farxiga, AstraZeneca).

More Prescriptions Is a "Good-News" Story

Asked to comment, specialist diabetes nurse at Diabetes UK, Libby Dowling, RGN, told Medscape Medical News: "A positive message that we can take from this story is that we are seeing people with type 2 diabetes getting the treatment that they need, and perhaps this is reflecting an increase in awareness — both in people themselves and among GPs — of type 2 diabetes as a serious condition. In recent years, we've seen a number of different drugs become available to treat type 2 diabetes," she said, noting that as a result of this, doctors now have many more options, and patients have more of an informed choice.

The figures indicate doctors are starting to prescribe some of these newer agents, she said, and the hope is that GPs "are actually now treating type 2 diabetes to target and really starting to tighten up on management of the condition in their patients." Naresh Kanumilli, MBBS, MRCGP, of Northenden Group Practice, Manchester, United Kingdom — a GP who specializes in the treatment of diabetes — agrees. "As well as indicating that the incidence of type 2 diabetes is increasing rapidly, which we know, these figures show that GPs are saying 'Let's deal with this more aggressively and try to tackle the disease at an earlier stage, " he told Medscape Medical News.

However, he warned that early medication use should not come at the expense of lifestyle advice and structured education programs.

"They do go hand-in-hand, and there is a difference in opinion as to whether we do the treatment, structured education, and lifestyle management at the same time, or do we do lifestyle and structured education first? And then if that fails, go to medication? Different people feel differently," he observed.

Also, GPs can be guilty of not properly stressing the importance of nonpharmaceutical approaches, he emphasized.

"GPs don't seem to promote structured education as a therapy; they say, 'You can try this as well' rather than saying, 'Well actually, this is a vital aspect of your treatment.' "

Nevertheless, he surmised, "I think this is good news on the whole. One of the things we've suffered with in the past is inertia — people not doing the right thing soon enough, in a timely fashion, which leads to more complications. This indicates GPs are trying to be more aggressive, managing patients sooner rather than later, and the advent of newer drugs has given them a little bit more confidence, [along with] trials indicating that earlier treatment has long-term benefits," he added.

And the sheer number of new therapies for type 2 diabetes means doctors can really start to tailor treatment to the individual, added Ms Dowling.

"What Diabetes UK would like to see is individualization, so that people coming to their doctors are treated as an individual rather than [clinicians] using a blanket approach," she stressed.

GPs Using Newer Drugs They Are Familiar With

Dr Kanumilli said that GPs simply cannot keep up to date with all the latest research in type 2 diabetes; instead, they rely on information from local experts.

While the latter will be guiding GPs and saying, " 'If you need to, just add on therapy sooner rather than later, to preserve beta-cell function,' the GPs themselves are more likely to be just focused on HbA1c and the target they need to achieve," he explained.

And with regard to the selection of specific new agents, he said the data show GPs are choosing the drugs they are most familiar with.

"Sitagliptin has been around for a long time, people have gotten used to it and are…comfortable with it [and] with the side-effect profile."

And dapagliflozin was the first SGLT2 inhibitor on the market in the United Kingdom, so "again there is more confidence with that," he explained, despite the fact that an alternative SGLT2 inhibitor, empagliflozin (Jardiance, Lilly/Boehringer Ingelheim), has since been shown to provide cardiovascular benefit in the large outcomes trial EMPA-REG.

And with regard to use — or lack thereof — of the subcutaneously administered glucagonlike peptide 1 (GLP-1) agonists — which are covered under the heading "other" and make up 8% of the prescriptions in the report — Dr Kanumilli observed: "This is a bit hit and miss. A lot of people are not keen on injections and view the next step as insulin and unfairly view insulin as the bad guy when actually it's the best treatment around. Some GPs seem to use insulin as the stick to beat people with — ie, if you don't do this, [you will end up on insulin,] which is the wrong thing to do," he stressed.

Again, figures for insulin prescribing are covered under the 8% of "other."

Most GPs in the United Kingdom will not initiate insulin for type 2 diabetes, Dr Kanumilli noted: "They will refer people to tier 2 facilities or hospitals for this," but they will prescribe it once a patient is stabilized on it.

The recent NICE guidance also came under fire for its decision to retain NPH as the first-line choice for basal insulin for type 2 diabetes, rather than allowing for use of newer analogs. And it was lukewarm on the GLP-1 agonists, although the latter might change in the wake of the positive results from the cardiovascular outcomes trial LEADER, reported earlier this year with liraglutide (Victoza, Novo Nordisk)

While acknowledging some of its shortcomings, Ms Dowling concluded that the NICE guidance on type 2 diabetes is "an excellent reference point" for GPs for the treatment of type 2 diabetes and "leaves quite a lot of options open to individual clinicians that they will use their own knowledge to interpret."