During my frequent visits to prescribers’ offices I get a chance to see their prescribing habits. When it comes to DPP-4 inhibitors, medical professionals seem to have similar opinions on how to use each of the drugs from this class. But to test this theory, we contacted 25 primary care physicians, and endocrinologist to get their feedback….
When asked, “Who is the ideal candidate for a DPP-4 inhibitor?”, the majority responded that they would consider the medication for most of their type-2 patients and that they would start them after the use of metformin. Interestingly a couple of the prescribers felt that if the co-pay was low enough they would use a DPP-4 inhibitor first. Four of the respondents indicated that they would start the DPP-4 inhibitor prior to reaching the maximum dose of metformin. The physicians who indicated that they would use a sulfonylurea before a DPP-4 inhibitor cited cost or insurance constraints as a reason.
- Someone not controlled on Metformin (56%)
- Someone not controlled on Metformin/sulfonylurea (16%)
- Unable to tolerate metformin (28%)
- After metformin (76%)
- After metformin/sulfonylurea (16%)
- Other (8%)
Since some of our patients have contraindications to metformin a majority of the prescribers felt that a DPP-4 inhibitor would be a first choice. Dr. C. Webber indicated that she used to go with the inexpensive glimepiride but has started using sitagliptin whenever insurance coverage is available.
For renally compromised patients the prescribers indicated they would cut the dose in half, and although most of them knew that linagliptin did not need to be decreased they seemed to feel more comfortable cutting the dose of sitagliptin or saxagliptin in half rather than using the newer drug linagliptin. Dr. F. Saba stated that he had been cutting the dose of sitagliptin for the past 4 years and did not think the switch to linagliptin was necessary.
- Yes (88%)
- No (12%)
- Decrease by 50% (88%)
- Select non renal drug (4%)
- Other (8%)
When asked about weight loss with a DPP-4 inhibitor, Dr. P. Kostamo mentioned that although he had never really seen weight loss with a DPP-4 inhibitor, he did feel that some of his patients had not continued to add weight at their previous rate. Most of the clinicians felt that the weight change did not occur but versus a sulfonylurea or thiazolidinedione they liked the fact that it did not cause weight gain.
- Weight loss (8%)
- Stop or decrease weight gain (20%)
- None (72%)
- Yes (92%)
- No (8%)
The use of DPP-4 inhibitors has increased over the past three years and this is because it seems to deliver the results in almost all the patients, and when we asked our participants if they feel that the DPP-4 inhibitors deliver on the A1c promise, overwhelmingly, the response was yes.
Dave Joffe, Editor-in-chief, Diabetes In Control