What Benefits Do Modern Antidiabetics Bring to Patients in Primary Care?
How has the life of patients who now have the opportunity to treat diabetes mellitus in general practice changed? And what do the current prescription conditions for modern antidiabetics bring to their treating physicians? We discuss this and more with diabetologist MUDr. Katarína Nováková.
How do you perceive the current role of general practitioners in diabetes treatment?
General practitioners are crucial for the diagnosis and management of care for patients with early stages of type 2 diabetes mellitus (DM2). Their offices see the largest segment of the population, especially during preventive check-ups when diabetes is often diagnosed. And early initiation of therapy is essential for achieving good compensation and preventing cardiovascular and microvascular complications. Moreover, general practitioners often know the families of their patients, which allows for targeted screening of diabetics.
Currently, there are over 1 million patients with type 2 diabetes in the Czech Republic, with approximately a quarter having no therapy. The current treatment options for diabetes are simple, even for general practitioners, and very safe for patients.
How should a general practitioner proceed with a newly diagnosed diabetes patient?
It is crucial to initiate therapy immediately after the diagnosis of DM2, which should be confirmed by standardized procedures such as repeated fasting venous blood glucose ≥ 7.0 mmol/l, random glucose ≥ 11.1 mmol/l with clinical symptoms, or glucose levels in the 120th minute of oGTT ≥ 11.1 mmol/l.
The drug of choice in DM2 therapy remains metformin (if not contraindicated), along with adjustments in lifestyle and dietary habits. The treatment should be titrated to the maximum subjectively tolerated dose (2000 mg, in some cases up to 3000 mg per day) to achieve target glycated hemoglobin (HbA1c) levels. If compensation is not satisfactory, antidiabetic therapy should be intensified upon reaching HbA1c ≥ 53 mmol/mol. Modern and safe medications with cardiovascular benefits are available for these cases today.
Early therapy is also crucial considering the so-called metabolic memory. How well diabetes is compensated in the first months to years subsequently determines the further development and compensation of the disease in the following periods. It is also known that diabetics suffering from hypertension and dyslipidemia have a high to very high cardiovascular risk. Therefore, the way to reduce this risk and prevent the development of cardiovascular complications is not to delay the initiation of treatment.
What does the term “modern antidiabetic treatment” mean, which antidiabetics fall into this category, and which of them can general practitioners prescribe?
Modern antidiabetic treatment includes preparations that improve diabetes compensation without an increased risk of hypoglycemia and have proven cardiovascular safety. The first modern antidiabetics were dipeptidyl peptidase 4 inhibitors (DPP-4i). Also included are sodium-glucose cotransporter 2 inhibitors (SGLT-2i), known as gliflozins, and glucagon-like peptide-1 receptor agonists (GLP-1RA) - these drug groups have not only demonstrated cardiovascular neutrality but also help in reducing weight and cardiovascular risks.
From the GLP-1RA group, general practitioners have access to oral semaglutide - the most effective available oral antidiabetic. Although gliflozins, approved for the treatment of diabetes, heart failure, and renal insufficiency, cannot be prescribed by general practitioners, it is worth mentioning that these drugs are advantageously combined with GLP-1RA or DPP-4i.
On the other hand, I consider sulfonylurea derivatives (DSU) to be obsolete because they often lead to a faster exhaustion of insulin secretion by the pancreas, limiting further treatment options. In such a case, no other effective therapy, apart from insulin therapy, works. Even though DSU are still overused, they are harmful in the long term due to the risk of severe hypoglycemia and weight gain.
Why is it advisable to start DM2 treatment with new antidiabetics?
Most patients with type 2 diabetes are of working age, and the ability to lead a full life and work is important for both them and society. The treatment with modern antidiabetics is simple, safe, and comfortable for the patient. Its main benefit is the extension of quality life and delaying the need for insulin therapy and the onset of micro- and macrovascular complications.
When should a GLP-1RA specifically be chosen?
A drug from this group should be considered and offered to the patient as a second choice if diabetes compensation is insufficient. It is indicated for all type 2 diabetics, especially with the presence of atherosclerosis and to prevent the development of atherosclerotic complications. The second option is to strengthen therapy with metformin by adding DPP-4i. DSU should not be the second choice therapy due to the aforementioned risks compared to modern antidiabetics.
What are the main benefits of the GLP-1RA group in brief?
These preparations safely reduce both fasting and postprandial glucose levels and lead to weight loss. They are safe, have a low risk of hypoglycemia, and act in the primary and secondary prevention of cardiovascular complications. Semaglutide also reduces inflammation and slows down atherosclerosis progression, improving cardiovascular health - it reduces the risk of stroke (CVA) by up to 1/3, stabilizes blood pressure, and improves the lipid profile. Its effects thus far exceed the mere improvement of glycated hemoglobin and glucose levels. Oral semaglutide is the most effective oral antidiabetic, which I can confirm from my own practice.
What are the reimbursement conditions for oral semaglutide? Do patients have to fear higher copayments?
This therapy is reimbursed by health insurance companies as the second choice after metformin at HbA1c ≥ 53 mmol/mol. The treatment with semaglutide has a deductible that counts toward the insurer's protective limit. This limit is a maximum of 5000 CZK per year and decreases with age. This is also the amount a patient pays for the medication annually. The deductible for oral semaglutide counts toward this protective limit. Practically, everything the patient pays beyond the protective limit in deductible copayments will be reimbursed by their health insurance company.
What should doctors and patients practically know about using oral semaglutide?
Oral semaglutide is a unique tablet designed to adhere to the stomach wall after ingestion and be directly absorbed into the bloodstream through the gastric mucosa. It is susceptible to degradation by stomach acids, and therefore its use has 3 important guidelines.
1. Take the tablet in the morning after waking up, after fasting for at least 6 hours.
2. Swallow it with a sip of water, no more than 120 ml.
3. Consume food or other medications at least 30 minutes after.
It is recommended to eat smaller portions more frequently to avoid potential digestive issues.
The dose of oral semaglutide is titrated gradually. There are 3 strengths: the initial dose is 3 mg, increasing to 7 mg after one month, and then to 14 mg after the next month. It is desirable to titrate the semaglutide dose to 14 mg, as this has the most significant effect in terms of improving diabetes compensation, weight loss, and cardiovascular benefits.
In summary, what have drugs from the GLP-1RA group brought to real practice...
In my practice, I frequently use oral semaglutide, so I can confirm its significant benefits for patients. I see a significant improvement in diabetes compensation, weight loss, and stabilization of blood pressure. Patients are often motivated by their weight loss to adhere to the therapy, leading to further lifestyle changes - they start exercising regularly and gain self-confidence. I see that they are happier and, most importantly, healthier.
The knowledge that this treatment delays the development of cardiovascular and microvascular complications is crucial for the patient. Additionally, if we help them achieve an improvement in health and weight loss, it strengthens their trust in the physician and the mutual relationship. It is amazing what treatment options we have for type 2 diabetes today, and it is up to us, the doctors, to fully utilize the potential of these drugs in our patients.
MUDr. Andrea Skálová
editor, proLékaře.cz
CZ24RYB00209
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