Are You Giving Your Patients With T2D the Meds They Want?

Patients with type 2 diabetes and their clinicians may not share the same priorities when it comes to choosing a second-line drug after metformin, new research suggested.

In a mixed-methods study of 40 people with type 2 diabetes and moderate heart disease risk who were asked about their goals, preferences, and priorities for glucose-lowering medications, their answers were surprisingly heterogeneous and not always aligned with those endorsed by the medical community.

Notably, most patients rated blindness and death as the most important health outcomes to avoid and efficacy in lowering blood glucose and A1c as the most important medication attributes. Avoidance of cardiovascular outcomes was ranked slightly lower. The data were published recently in Clinical Diabetes.

“We really need to ask our patients about what is important to them. That’s how you have a relationship and engage in shared decision-making,” lead author Rozalina G. McCoy, MD, Associate Division Chief for Clinical Research in the Division of Endocrinology, Diabetes, and Nutrition at the University of Maryland, Baltimore, told Medscape Medical News.

Patient education should be approached in that way, she added. “They might not think their diabetes is related to heart disease risk or that anything they do can impact it. That’s a conversation starter…We first have to understand what motivates them and then tailor education to what is important to them,” she said.

Asked to comment, endocrinologist Cecilia C. Low Wang, MD, Professor of Medicine at the University of Colorado, Aurora, told Medscape Medical News, “the fact that death and blindness are key health outcomes in the patients surveyed indicates to me that patients place great importance on ‘irreversible’ bad outcomes. We as clinicians do not tend to discuss benefits for all-cause mortality with our diabetes medications. Maybe we should include this in our discussions.”

Low Wang also noted, as did McCoy, that the emphasis on lowering glucose reflects decades of public health messaging, and that while it’s certainly important, particularly for microvascular outcomes, it’s just one of several factors influencing cardiovascular and all-cause mortality risk.

“I think what this finding tells us is that we need to focus on a more nuanced message of improved glycemic control and reduction of risk of both micro- and macrovascular complications and weight management, healthy diet, and regular physical activity…that it is not just glycemic control that is important but glycemic control in the context of a healthy lifestyle and good overall health,” Low Wang said.

Blindness and Death Bigger Concerns Than Heart Attack or Heart Failure

The study participants included 25 from the Mayo Health System in Rochester, Minnesota (where McCoy formerly worked), and 15 from Grady Memorial Hospital in Atlanta, Georgia. Half were White, and just over a third were Black. All had active prescriptions for a glucagon-like peptide 1 receptor agonist, sodium-glucose cotransporter 2 inhibitor, dipeptidyl peptidase 4 inhibitor, and/or a sulfonylurea.

They were first given a multistep ranking exercise regarding health outcomes and medication attributes selected from a list and then were asked to add any others that were important to them and re-ranked the entire list.

For health outcomes, the most common listed as “very important” were blindness (63%) and death (60%), followed by heart attack (48%) and heart failure (48%). Those endorsed less often were hospital admission (28%), severe hypoglycemia (25%), and pancreatitis (15%).

Low Wang noted, “Heart attack and heart failure and stroke were not far behind…Maybe the messaging about risks of [atherosclerotic cardiovascular disease] in diabetes is working at least to some degree and in some populations.”

Combinations of outcomes selected as “very important” varied widely, with just one combination (end-stage kidney disease, heart attack, blindness, and any event causing death) endorsed by more than a single participant. This was unexpected, McCoy noted.

“Usually, a qualitative study is very small, so we thought 40 was huge and we’d see a lot of similar things, but I think the first surprising finding was just how much variability there is in what people with type 2 diabetes consider as motivating factors for choosing a diabetes medication…So when we talk about patient-centered care and shared decision-making, that’s really important because patient priorities are very different,” she said.

For medication attributes, greater reductions in blood glucose and A1c were most often endorsed as “very important” (68%), followed by oral administration (45%) and absence of gastrointestinal side effects (38%).

Nearly half (47.5%) added one or more outcomes as important to them in deciding on a medication for type 2 diabetes. The most common had to do with affordability (n = 10), minimizing the total number of drugs (n = 3) and avoiding drowsiness (n = 2).

Low Wang commented, “Some of the health outcomes we as clinicians feel are important, such as serious infection, hospitalization, kidney dysfunction or failure, and diabetic foot problems, were not felt to be as important to the patients surveyed. This could be due to other health outcomes outweighing these, or highlights the need for more focus, education, and discussion with patients.”

Five Themes Describe Patients’ Perceptions of Health Outcomes

Throughout the ranking process, a researcher asked participants (via phone or Zoom) about their reasons for ranking items as “very important” or “not very important” in choosing medications. For health outcomes, five broad themes emerged from their comments: The outcome’s severity (with permanence and potential lethality prominent), their perceived personal susceptibility to it, salience (ie, whether they knew someone who had experienced the outcome), their beliefs about causation, and about the consequences of the outcome.

With medication attributes, the medication’s ability to lower blood glucose was deemed a priority by nearly all. By contrast, there was much more variation in the responses regarding the influence of various side effects in their decision-making based on personal preferences, beliefs, and previous experiences.

This paper is one part of research funded by the Patient-Centered Outcomes Research Institute (PCORI) examining the effects of second-line glucose-lowering medications in patients with type 2 diabetes who are at moderate, rather than high, cardiovascular risk. The main paper, looking at prespecified cardiovascular outcomes, is scheduled to be published soon, McCoy said.

She’s now planning a follow-up study to look at actual outcomes for the second-line drugs based on the patients’ preferences. “We don’t have the evidence necessarily to tell our patients what is best given their specific preferences…The question is, if our patients tell us what they want, how would that change what we recommend to them?”

The study was funded by PCORI. McCoy received support from the National Institutes of Health and AARP. She also served as a consultant to Emmi (Wolters Kluwer) for developing patient education materials related to prediabetes and diabetes. Low Wang received research support from Dexcom Inc, Virta Health, and CellResearch Corp within the past 24 months.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape Medical News, with other work appearing in the Washington Post, NPR’s Shots blog, and Diatribe. She is on X: @MiriamETucker.