Cases of diabetic polypharmacy were identified where patients were receiving more than three blood glucose-lowering therapies, suggesting clinical inertia towards insulin. This also suggests that current therapy had been added to, rather than reviewed and stopped if the therapies gave no sufficient reduction in HbA1c.
Cases were also identified in which medication should have been stopped owing to the patient’s poor kidney function. Numerous cases of patients receiving both GLP-1 mimetics and DPP-4 inhibitors were found, which suggested a lack of awareness of mechanisms of action — both these agents work on the same pathway. These messages were highlighted to clinicians during the project.
There was a clear focus on improving quality of prescribing, which clinicians valued. Feedback on the project was very positive; clinicians enjoyed the holistic discussions and the presentation of patient cases using the EMIS Health template, which made it clear where NICE-recommended HbA1c and weight reductions had not been achieved.
A lack of awareness of NICE guidance was apparent, in relation to both initiation and monitoring of these agents. Many clinicians were unaware of the initiation criteria and the six-month targets to continue: both a reduction in HbA1c and weight are required. Additionally, it was noted that GLP-1 mimetics were frequently added to patients’ repeat prescription record in quantities not aligned to the dose, resulting in inadvertent over-ordering. This opportunity was used to develop local guidance and resources to support our clinicians.
We continue to share the legacy messages of this project and encourage clinicians to refer to our formulary GLP-1 mimetic initiation flowchart and GLP-1 mimetic patient contract when initiating these agents; document the targets for continuation at six months; and prescribe an appropriate quantity of devices. These resources are available on our formulary website.