Approaches to and inertia in cardiovascular and renal risk management of Type 2 diabetes patients in primary care:Results from a global quantitative surveyStephen Brunton1, Xavier Cos2, Gary Deed3, Naresh Kanumilli4, Pamela Kushner5, Peter Lin6, and Johannes Nolte7

1. Primary Care Metabolic Group, Los Angeles, CA, USA; 2. Sant Marti de Provençals Primary Care Centres, Institut Català de la Salut, Barcelona, Spain; University Research Institute in Primary Care (IDIAP Jordi Gol), Barcelona, Spain; 3. Chair, Diabetes Specific Interest Network RACGP; Adjunct Senior Research Fellow, Monash University, Melbourne, VIC, Australia; Medical Director, Mediwell, Coorparoo, QLD, Australia; 4. Community Diabetes Consultant, Manchester University Foundation Trust, UK; GPSI Diabetes and Cardiology, Northenden Group Practice, Manchester, UK; 5. Family Medicine, University of California School of Medicine, Irvine, CA, USA; 6. Canadian Heart Research Centre, North York, ON, Canada; 7. Hausärztliche Gemeinschaftspraxis, Köln, Germany

Presented at the American Diabetes Association 80th Scientific Sessions Virtual Conference, June 12th–16th, 2020

1

2DISCLOSURES

S. Brunton: Advisory Panel – Abbott, Bayer US, Merck & Co., Inc., Xeris Pharmaceuticals, Inc. Speakers Bureau – Bayer US, Lilly Diabetes, Novo Nordisk Inc. Other Relationship – AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc., Novo Nordisk Inc. X. Cos: Advisory Panel – AstraZeneca, Boehringer Ingelheim International GmbH, Lilly Diabetes, Novo Nordisk A/S, Sanofi. Speakers Bureau – AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Lilly Diabetes, Novo Nordisk A/S, Sanofi. G.F. Deed: Advisory Panel – AstraZeneca, Boehringer Ingelheim International GmbH, Lilly Diabetes. Speakers Bureau – AstraZeneca, Boehringer Ingelheim International GmbH, Lilly Diabetes, Merck Sharp & Dohme Corp., Novartis AG, Novo Nordisk Inc., Sanofi-Aventis. N. Kanumilli: Advisory Panel – Abbott, AstraZeneca, Boehringer Ingelheim International GmbH, Janssen Pharmaceuticals, Inc., Novartis AG, Novo Nordisk A/S. Consultant – Boehringer Ingelheim International GmbH, Sanofi-Aventis. Speakers Bureau – Napp Pharmaceuticals. P.R. Kushner: Advisory Panel – Abbott, AstraZeneca, Bayer US, Janssen Pharmaceuticals, Inc., Novo Nordisk Inc. Speakers Bureau – AstraZeneca, Janssen Pharmaceuticals, Inc. P.J. Lin: Speakers Bureau – Abbott, AstraZeneca, Bausch + Lomb, Bayer Inc., Boehringer Ingelheim (Canada) Ltd, Eli Lilly and Company, Mead Johnson Nutrition, Merck & Co., Inc., Novo Nordisk Inc., Sun Pharmaceutical Industries Ltd. Other Relationship – Elsevier. J. Nolte: Advisory Panel – AstraZeneca.

This global survey of primary care physicians (PCPs) and primary care diabetes specialists (PCDSs) investigated current approaches to the early cardiovascular (CV) and renal risk management of patients with Type 2 diabetes (T2D), to identify key points of treatment inertia

3OBJECTIVES

1. Emerging Risk Factors Collaboration et al. Lancet 2010 375:2215–2222; 2. Baena-Díez JM. et al. Diabetes Care 2016 39:1987–1995; 3. Cheng YJ. et al. Diabetes Care 2018 41:2306–2315; 4. Rawshani A. et al. NEJM 2017 376:1407–1418; 5. Sanchez-Rangel E. et al. Diabetologia 2017 60:1586–1593; 6. Buse JB. et al. Diabetes Care 2020 43:487–493; 7. Bailey CJ. International Journal of Clinical Practice 2016 70:988–995; 8. Khairnar R. et al. Journal of Pharmaceutical Health Services Research 2019 10:117–123; 9. Reach G. et al. Diabetes & Metabolism 2017 43:501–511

REFERENCES

BACKGROUND

4 Despite recent recommendations for the use of glucose-lowering therapies with additional CV and renal benefits, as demonstrated through CV outcomes trials (CVOTs), many patients with T2D managed in primary care remain on therapeutic regimens that do not offer benefits beyond glucose lowering7–9

For patients in whom first-line metformin monotherapy does not control glucose levels adequately, guidelines recommend that metformin be combined with new second-/third-line therapies, including sodium–glucose co-transporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and dipeptidyl peptidase-4 (DPP-4) inhibitors5,6

Cardiovascular disease (CVD) remains the leading cause of death among people with T2D; the risk of CVD and death from CV causes is two to three times higher than in the population without T2D1–4

METHODS

Because PCDSs are commonly or exclusively responsible for the primary care of patients with T2D in Brazil, Germany, and Turkey, PCDSs were recruited in addition to or instead of PCPs in these regions

Study design

Web-based quantitative panel survey of PCPs and PCDSs; conducted in November and December 2019

Included countriesa

Inclusion criteriaSeeing T2D patients for >1 year

Saw >20 patients a month

Responsible for T2D diagnosis, treatment initiation, or ongoing management of patients with T2D

aParticipant quotas were predefined for each country and the survey was closed when quotas were reached.DPP-4, dipeptidyl peptidase-4; GLP-1, glucagon-like peptide-1; PCDS, primary care diabetes specialist; PCP, primary care physician; SGLT2, sodium–glucose co-transporter 2; T2D, Type 2 diabetes

United ArabEmirates

United Statesof America

ArgentinaAustraliaCanada

Denmark

UnitedKingdom

Kingdom ofSaudi Arabia

MexicoNorway

South KoreaSpain

DenmarkEgyptIndia

Sweden

PCPsBrazil (15%)

Germany (15%)Turkey

PCDSs

5Questions covered the current management of patients with T2D,

particularly the use of second-/third-line therapies (SGLT2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors)

8screeningquestions

5Likert scale questions

3ranking

questions

1 multiple-choice

question

Questionnaire

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consec

Surveycompleted by

from18 countries

1558 PCPs

119 PCDSs

and

Respondents saw a mean of 132 patients with T2D per

month and had treated patients with T2D for 17 years

were responsible for second-/third-line treatment initiation

Responsibilities of respondents for T2D patient care

and73% PCPs

72% PCDs

RESULTS – SURVEY PARTICIPANTS

PCDS, primary care diabetes specialist; PCP, primary care physician; T2D, Type 2 diabetes

6 Treatment initiation

Diagnosis

Ongoing management

178(10.6%)

162(9.7%)

223(13.3%)

165(9.8%)

55(3.3%)

96(5.7%)

798(47.6%)

agreed that early intensification to second-/third-line therapies in

accordance with clinical guidelines is associated with

clinically relevant benefits

reported that their own clinical experience was

a very important source of guidance for daily

treatment decisions

and

of PCPs of PCDSs of PCPs of PCDSs

and 65%72%7RESULTS – TREATMENT DECISIONS

PCDS, primary care diabetes specialist; PCP, primary care physician

81% 87%

Barriers to second-/third-line therapy prescription

% respondents

‘Great’ barriers ‘Moderate’ barriers

0% 10% 20% 30% 40% 50%

The local healthcare system / insurance companies restrict access to these therapies 21% 29%A lack of interest in their condition leads most patients to delay appointments or ignore them

all together 16% 28%Owing to administrative and healthcare system restraints, maintaining regular appointments

with patients can lead to treatment inertia 17% 27%Guidelines are not clear about which patients these treatments are specifically for 10% 33%

I am concerned about the side effect profile of these therapies 18% 24%

These therapies are not as easy to initiate as other therapies 16% 24%

Guidelines are not clear about how best to intensify a patient’s treatment with these therapies 16% 22%I don’t have enough experience in prescribing and managing newer Type 2 diabetes therapies 11% 23%

8RESULTS – BARRIERS TO PRESCRIPTION

had changed their treatment decisions based on these trials

and 58% PCDSs68% PCPswould maintain current therapies in a well-controlled patient, despite

increased patient CV risk

and23% PCPs 29% PCDSs

tend to reserve SGLT2i and GLP-1 receptor agonist treatments for

later lines of therapy

and47% PCPs 39% PCDSs

were aware of data published from recent CVOTs

and 52% PCDSs68% PCPs

believed that CVOT data demonstrated SGLT2 inhibitors and GLP-1 receptor

agonists to have CV and renal benefits beyond glucose lowering

and71% PCPs 69% PCDSs

felt that the clinical implications of these trials were unclear

and43% PCPs 46% PCDSs

9RESULTS – CVOT DATA AND CV RISK

CV, cardiovascular; CVOT, cardiovascular outcomes trial; GLP-1, glucagon-like peptide-1; PCDS, primary care diabetes specialist; PCP, primary care physician; SGLT2, sodium–glucose co-transporter 2

This study was funded by AstraZeneca. We would like to thank Derah Saward-Arav, integrated medhealth communication (imc) for medical writing support, and Alma Aceituno Herrera, imc, for graphical design assistance, funded by AstraZeneca.

ACKNOWLEDGMENTS

10Significant barriers still prevent the optimization of T2D patient care in the primary setting, including:

CONCLUSIONS

Limited familiarity of PCPs and PCDSs with new CVOT data

Treatment inertia

Access restrictions for second-/third-line treatments

CVOT, cardiovascular outcomes trial; PCDS, primary care diabetes specialist; PCP, primary care physician; T2D, Type 2 diabetes