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Diabetologists try to block GP use of new diabetes drugs

Consultant diabetologists have launched an attempt to prevent GPs prescribing the newest class of type 2 diabetes drugs.

NICE recommends GPs consider the gliptins or a glitazone as alternatives to a sulfonylurea ‘if there is a significant risk of hypoglycaemia', or if a patient is intolerant of sulfonylurea or has a contraindication.

Sitagliptin is also recommended as a third-line option instead of insulin. Exenatide can be used as a third-line option too, but only for patients with a BMI more than 35 kg/m2.

But the Association of British Clinical Diabetologists (ABCD) has courted accusations of protectionism by cautioning against ‘indiscriminate use' of the new classes of drugs by GPs.

Dr Peter Winocour, ABCD chairman and a consultant in endocrinology at the Queen Elizabeth II hospital in Welwyn Garden City, told Pulse GPs should only use the gliptins and exenatide in a ‘selected number of patients with extreme caution'.

He said the association's research in over 7,000 patients had highlighted the need for GPs to select patients only with advice from secondary care specialists.

‘We think the use of the newer drugs is something that primary care should be using with extreme caution.

‘We have learned from past experience with other novel diabetes therapies that adverse side effects can become apparent even after pre-licensing testing.

‘Obviously there are GPs with an interest in diabetes who may work closely with secondary care specialists. But the vast majority of GPs would not seek active input from specialists.'

The association insists patients at risk of pancreatitis, with a history of gall stones or those on steroids should only be considered for exenatide under specialist supervision. People who drive for a living and those who have had or are contemplating bariatric surgery also require specialist input.

Dr Colin Kenny, a GP in Dromore, Northern Ireland and a member of the Primary Care Diabetes Society steering committee said he did see the need for specialist input for some patients.

But he added: ‘The NICE guidance made no distinction and the license is for use in primary care. I agree that many patient have very complex needs, and some diabetologists co-prescribe exenatide with insulin, for which there is not a license and does need extra expertise.

‘But I don't feel there anything about the GLP-1 drugs or the gliptins that requires specialist knowledge. I've used them quite a bit in my practice where they fit in with NICE guidance and they are easier to initiate than insulin – if a practice that has experience initiating insulin will be able to use exenatide.'

How diabetologists want the new drugs to be used How diabetologists want the new drugs to be used

Exenatide

  • Exenatide is not currently recommended to be started in anyone with high alcohol intake or fasting hypertriglyceridaemia>6mmol/L

  • If there is a history of gall stones, exenatide should only be considered by a specialist diabetologist in carefully monitored situations, and patients should be warned to stop treatment if abdominal pain ensues , where appropriate investigations should be initiated.

  • Gliptins
  • Avoid gliptins if eGFR<>

  • Measure baseline LFTs prior to initiation of vildagliptin; stop if three-fold rise

  • Patients on gliptins must be carefully monitored for possible hypersensitivity reactions

  • Diabetes

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