Permission to prescribe: do cardiologists need permission to prescribe diabetes medications that afford cardiovascular benefit?

Purpose of review Antihyperglycemic therapies including sodium glucose contransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) have been demonstrated to confer significant cardiovascular benefit and reduce future events in patients with type 2 diabetes mellitus (T2DM). However, despite positive data from cardiovascular outcome trials, these therapies remain underutilized in a large proportion of patients who have clinical indications and meet coverage guidelines for their initiation. One of the causes of the observed gap between scientific evidence and clinical cardiology practice is therapeutic hesitancy (otherwise known as therapeutic inertia). The purpose of this review is to discuss the contributors to therapeutic hesitancy in the implementation of these evidence-based therapies and, more importantly, provide pragmatic solutions to address these barriers. Recent findings Recent studies have demonstrated that clinicians may not initiate cardiovascular protective therapies due to a reluctance to overstep perceived interdisciplinary boundaries, concerns about causing harm due to medication side effects, and a sense of unfamiliarity with the optimal choice of therapy amidst a rapidly evolving landscape of T2DM therapies. Herein, we describe a multifaceted approach aimed at creating a 'permission to prescribe' culture, developing integrated multidisciplinary models of care, enhancing trainees' experiences in cardiovascular disease prevention, and utilizing technology to motivate change. Taken together, these interventions should increase the implementation of evidence-based therapies and improve the quality of life and cardiovascular outcomes of individuals with T2DM.

Automated summary

Despite significant cardiovascular benefit of SGLT2 inhibitors and GLP-1 receptor agonists in T2DM patients, these therapies are underutilized due to therapeutic hesitancy. Clinicians may be reluctant to initiate cardiovascular protective therapies due to concerns about crossing interdisciplinary boundaries, potential harm from medication side effects, and uncertainty about optimal therapy choice. Multifaceted approaches, such as creating a culture of 'permission to prescribe' and enhancing trainees' experiences in cardiovascular disease prevention, are proposed to increase the implementation of evidence-based therapies and improve outcomes for individuals with T2DM.