Aifa has decided that even general practitioners (and nephrologist and cardiologist specialists), in addition of course to diabetic specialists, can prescribe second-level drugs for type 2 diabetes, those – to understand us – that need a plan therapeutic and therefore could only be prescribed in specialized centers. For years the associations of diabetic doctors have all been asking that general practitioners also be able to prescribe these drugs, for two reasons: the first is that many of these, in addition to indisputable effects on blood sugar control, have a very positive effect on prevention. cardiovascular and renal failure, two of the complications of the disease, and therefore allow to protect the patient more. The other reason is very simple: apart from metformin, which is and remains an irreplaceable first-line drug, to general practitioners (who treat more than half of patients with type 2 diabetes, about 3.5 million in Italy and an estimated one million undiagnosed) was reserved for the prescription of drugs that lose efficacy in the long term, if not downright dangerous, such as sulfonylureas, which in the new guidelines of the scientific societies published by the Istituto Superiore di Sanità have been banned and therefore they can no longer be prescribed and used.
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From today, general practitioners can also use all available molecules in their treatment armamentarium. But not in association with each other, a prescription that continues to be reserved for specialists. The point now is: do they know how to use them? “In fact, up to now these drugs have been the prerogative of specialists – he reasons Andrea Giaccari, a diabetologist at the Gemelli University Hospital Foundation in Rome – and for this reason his colleagues in general medicine were not at the congresses where they were presented, nor are they visited by the companies that produce them. Obviously it will begin, and it will have to be done both to respect the guidelines, approved by the Higher Institute of Health and therefore “state law”, and to give benefits to patients. The critical issue I see is the budget to which general practitioners are called up by the ASL, because these drugs are more expensive than those prescribed so far “.
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The great advantage – for specialist centers – is that the general practitioner can be delegated the renewal of the treatment plan, avoiding flooding the hospitals. “A shared management – specifies Giaccari – we bring the patient to the correct target and we review him after two years, while he is followed by the general practitioner, who turns to the specialist only in case of worsening in the management of the disease. If the specialized centers are lightened by the presence of patients who come every six months for the renewal of the treatment plan, which fortunately has now been extended to 12 months, we will have more time to deal with the more complicated cases “.
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The drugs we are talking about – and which Aifa talks about in note 100 – are essentially of three classes: Sglt2 inhibitors, Glp1 receptor agonists and Dpp4 inhibitors. Let’s see together the advantages and limitations of each category.
“Dpp4 inhibitors are the easiest to use – continues Giaccari – because they have no side effects, but not even advantages, except obviously in terms of blood sugar reduction in the absence of risk for hypoglycemia. And they can be considered as second-line drugs (after metformin) in patients for whom the doctor believes that the side effects of the other two drugs may constitute a contraindication for the patient, for example excessive weight loss in an already too thin patient. and frail (effect of Glp-1) or in a patient who knows he has recurrent genital infections (effect of Sglt-2). “
When protection is on the heart and kidneys
The other two categories have – in addition to the reduction of blood sugar – important additional advantages, so much so that for example the reimbursement of Sglt-2 has been extended to patients with heart failure but without diabetes. Hence a significant cardiovascular protective effect. “Sglt-2 inhibitors are taken orally and can be used with metformin, or alone if there is an intolerance to metformin. With protection for renal failure and heart failure, but also for cardiovascular events. In the first two weeks – specifies the specialist – there is an increase in diuresis, which can be a problem for those with very low blood pressure or for those at risk of dehydration. However, it is sufficient to inform the patient. Genital infections are also more frequent, especially in women by conformation, but can be dealt with with greater hygiene, even without soap. Considering that urine becomes rich in glucose, these drugs are not recommended for those with recurrent mycosis “
The side effects
Finally, the prescription of Glp-1 is preferred, generally injective but now also available orally, if – in addition to diabetes – the patient has a risk of atherosclerosis or heart attack, plaques in the arteries or other cardiovascular risk factors. “As side effects Glp-1 mainly give gastrointestinal disorders with diarrhea or rarely constipation – continues Giaccari – nausea and rarely vomiting, the same side effects of metformin, which however disappear after 4-8 weeks”.