"When I went to school, all we had was insulin and sulfonylureas...metformin was a big deal when it came out." With new drugs approved every year now, how do you decide when to try them?
The science of endocrinology, particularly in the field of diabetes, has exploded in the last few decades. With that explosion have come many new medications and important technological advances. I date myself by admitting that when I went to school, all we had was insulin and sulfonylureas-first- and second-generation sulfonylureas. Metformin was a big deal when it came out. And we got all excited over the introduction of troglitasone, the first TZD. Until the big recall.
Which brings me to my topic-with all the new medications and their new mechanisms of action, when do physicians start using them? As soon as they are available? After colleagues have tried them for a while? Or after a couple of years go by and the kinks have been worked out?
Personally, if I believe in the science behind a drug, say, if I like its mechanism of action, I have no problem using it right away in the appropriate patient. I understand there is an inherent risk to that. If something bad only happens one in a million times, it may not occur during clinical trials, and may only rear its ugly head after 3 or 4 million people have tried it.
I know other physicians wait a few months. They wait to see if there are any post-marketing reports of unexpected adverse effects. I suppose this also gives the pharmaceutical company time to negotiate with prescription plans to improve the drug’s coverage.
There are also hold-outs. Old-school physicians, if you will. Those who will only prescribe that which they have prescribed for the last 15 years. They know what works. They know what the expected side effects are. And the drugs are usually cheaper. Trouble is, many patients need more than metformin and a sulfonylurea, and many of those patients are not quite ready for insulin yet. If their doctor isn’t ready to prescribe something in a newer class, what are they to do?
There are pros and cons to be being willing to prescribe something new. In the end, we must weigh the risks and benefits and do what is best for our patients.
What’s your general strategy when a new antihyperglycemic agent is introduced? Would you share an experience, positive or negative, and a lesson learned?