Try to think of a drug that you have prescribed for the first time or prescribe infrequently, a template for this exercise can be downloaded here.

Example

Try to think of a drug that you have prescribed for the first time or prescribe infrequently

Name of drug

Dapagliflozin

Mode of action

A new oral treatment for type 1 or 2 diabetes – works on the renal tract to inhibit SGLT2. SGLT2 resorbs glucose from the renal tubules. Inhibiting it deliberately causes more glycosuria – keeping blood glucose down, losing calories. It does take some water with it but voiding only increased by another 1.5 times a day, there are more UTIs and thrush however. The extra water loss can help lower BP. 

Why did I choose this drug?

I have a few patients who have maximised oral therapy on metformin, gliclazide and a gliptin. Their HbA1c has remained elevated however and they really do not want to be referred for hospital care and potentially injectable medications.

What was I trying to achieve for this patient?

The particular patient in question is a 65 year old man whose diabetes has become increasingly harder to control on a combination of metformin and gliclazide and a gliptin and as he has had diabetes for greater than 10 years, it is likely he has a degree of myocardial ischaemia and so pioglitazone is too risky an option. He would find travelling to hospital very difficult as an amputee with mobility problems and no carers. His options are probably limited to a GLP-1 agonist or insulin therapy. I am hoping to see improved glycaemic control with a reduction in his HBa1c from the current 8.8% to closer to 8 or below.

Is this the most effective drug in this situation?

Given that only a glitazone is the only other primary care option and he does not want to be referred and there is a possibility of achieving close to optimal HbA1c – yes.

 

Learning points or changes made

I have learned though reading up on dapagliflozin that it should not be used in patients older than 75, for those on loop diuretics or volume depleting drugs and those with an eGFR of < 60 (which is not unusual for my diabetics so its use will be limited). I will caution patients about side effects such as increased risk of hypos if taking gliclazide and potential for UTIs. I have seen hospital consultants using this drug and after discussion at a recent educational meeting, they are happy for GPs to start initiating it.