According to findings from a Latin American research team, patients with type 2 diabetes prefer pharmacologic treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitors over treatment with dipeptidyl peptidase-4 (DPP4) inhibitors.
The findings of this study were published in Patient Preference and Adherence and highlight the need for clear discussions between patients and physicians before defining a treatment strategy.
José Esteban Costa Gil, MD, PhD, an endocrinologist at the La Plata Institute of Cardiology in La Plata, Argentina, commented that “taking into account the preferences and needs of patients while designing treatment can help improve therapeutic compliance.”
Costa, president of the Latin American Diabetes Association, added, “This thereby improves the quality and safety of medical care.”
The study showed that when given treatment information, 88.2% of participants preferred SGLT2 inhibitors over DPP4 inhibitors.
Carmen Castillo Galindo, MD, an endocrinologist from Mexico City who is highly specialized in diabetes, observed that these data allow for interesting reflections. In her experience, primary care physicians in Mexico usually prescribe DPP4 inhibitors. It is not until the patient sees a specialist that the treatment switches to SGLT2 inhibitors. Galindo did not participate in the study.
In fact, Galindo stressed that the benefits of SGLT2 inhibitors exceed those of DPP4 inhibitors, because of better glycemic control and because of the benefits of cardiovascular and renal protection. This explains specialists’ tendency to prescribe SGLT2 inhibitors more frequently, since patients with diabetes generally have heart or kidney disorders and obtain extra benefits from glycemic control.
“When discussing treatment benefits with patients, clearly they are going to choose the one that gives them the most [benefit]. That is why I attribute the discrepancy between patient preference and the treatment they receive as a result of the patient not being given options,” the specialist added.
This idea is in accordance with the study authors’ observations. They highlighted that the healthcare team seldom takes patient preference into account, even though achieving the desired health goals depends largely on therapeutic acceptance and compliance.
What Patients Value
The multicenter study enrolled 390 patients with type 2 diabetes from Mexico and Argentina. Between June and September 2020, the patients completed a discrete choice questionnaire to indicate their preferences between treatment with SGLT2 inhibitors and treatment with DPP4 inhibitors.
Overall, 88.2% of participants preferred treatment with SGLT2 inhibitors over treatment with DPP4 inhibitors. In addition, older participants (P = .0346), those with overweight or obesity (P < .0001), high blood pressure (P < .0001), high total cholesterol (P = .0360), and glycosylated hemoglobin (A1c) greater than 7% (P = .0001) were more likely to choose SGLT2 inhibitors.
The most and least important reasons for a patient to choose either drug were A1c reduction and genital infection risk, respectively.
One possible explanation for patients preferring one treatment over another is because its effect on A1c involves the management of type 2 diabetes. Physicians and patients continue to focus on the monitoring and control of A1c and not on a holistic approach that encompasses the risks and comorbidities associated with type 2 diabetes, according to the researchers.
On the other hand, patients did not place as much importance on the increased genital infection risk as a side effect of treatment, so Castillo stressed the importance of discussing all treatment details with patients.
“Virtually the only contraindication to prescribing SGLT2 inhibitors would be a patient who has a current urinary tract infection or who is known to have a urinary tract disorder that makes them more susceptible to chronic urinary tract infections,” Castillo explained.
The Importance of Autonomy
The authors of the study concluded that patient-centered care, which seeks a deep understanding of patients’ preferences and information needs, would improve personal satisfaction and health. But there are also ethical implications to consider.
Susana Vanoni, MD, PhD, is an expert in bioethics and professor at the School of Medical Sciences at the National University of Córdoba, Argentina. “Respect for the patient’s treatment preferences is an option that is based on the principle of autonomy, limited by that of distributive justice. Therefore, it is important for the physician to spend time explaining different regimens that offer a similar safety and efficacy profile, also considering major costs and coverage when making the recommendation,” she told Medscape Spanish Edition.
Certain factors, such as experience in the use of certain treatments, can make it difficult for health staff to discuss options and take the patient’s preference into account.
“And yet another factor is involved: the professional’s ongoing education. Accessibility to ongoing education is very uneven in the Americas, and, as an aggravating factor, health centers don’t invest in professional training, or do so inconsistently. In fact, this would be a topic for wider debate. The pharmaceutical industry frequently provides expenses for training, and potential conflicts of interest can arise when talking about medications,” said Vanoni.
Conflicts of interest related to DPP4 inhibitors could arise, said Castillo. “It’s a hypothesis, it’s not something I’m sure of, but DPP4 inhibitors have been on the market for longer, and since primary care physicians may be more used to prescribing them, they may not be as up to date on the benefits of new treatments. Or perhaps patients have been on that treatment for years, and it’s no longer being changed.”
There is also the factor of doctor–patient communication, including consultation length, which can be limited by institutional guidelines, said Vanoni.
“Another element that reduces communication time between doctor and patient is the administrative burden healthcare professionals have to endure. There is an obligation to complete, sometimes even by hand, lengthy forms justifying therapeutic and diagnostic procedures. This can also be hampered by preparing a prescription in an electronic system that is not user-friendly or has poor connectivity.”
This is the first study carried out in Latin America that analyzes the oral treatment preference among patients with diabetes. The authors believe that their study can help healthcare professionals educate their patients and make shared decisions to improve the management of type 2 diabetes.
The study was funded by AstraZeneca. Costa has reported receiving speaker/advisor/consultant fees from AstraZeneca, Novo Nordisk, and Abbott. He is also president of the Latin American Diabetes Association. Castillo and Vanoni have reported no relevant financial relationships.
This article was translated from the Medscape Spanish edition.
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