Addressing the concerns of people with diabetes

The past two decades have seen the introduction of new therapies for the management of type 2 diabetes. In the early 1990s treatment choices were easy; metformin for those who were overweight and a sulphonlyurea for those people with a normal body weight. Insulin was, wrongly, often used as a last resort. Since then several new medications have become available. Some, such as acarbose, have made a fleeting visit but have largely disappeared from clinical practice mainly due to uncomfortable side-effects. Others, such as troglitazone and rosiglitazone, were withdrawn due to safety concerns, although the safe use of rosiglitazone continues to be debated.

Media scrutiny
More recently the incretin-based therapies (glucagon-like peptide-1 [GLP-1] receptor agonists and dipeptidyl peptidase-4 [DPP-4] inhibitors) have been subject to media scrutiny. In June this year, the Channel 4 programme Dispatches reported, in conjunction with the BMJ (Cohen, 2013), that research had suggested that these medications may be associated with an increased risk of pancreatitis and pre-cancerous cellular changes of the pancreas. This is of obvious concern for those who are currently taking these medications and DSNs are often the first port of call for these people. In our own centre we had many calls following the programme and several people had stopped their medication. So how should we deal with this? It is often difficult for healthcare professionals to fathom the literature around controversial issues but people will be looking to us for informed advice.   

Following this programme, the Medicines and Healthcare products Regulatory Agency (MHRA) issued a statement highlighting that healthcare professionals should continue to prescribe these medicines in line with the product information and that there is no need for people using these medicines to stop taking them (MHRA, 2013).

The European Medicines Agency (EMA) is currently investigating the information provided by the researchers to determine the need for any change to the way these products are used (EMA, 2013). The MHRA is providing input to this assessment, which is ongoing; the EMA has not yet reached any conclusions.

The MHRA (2013) statement reminds us that the potential risk of pancreatitis has been known for some time and should be discussed with people with diabetes before starting these medications. In addition, my personal view is that we should discuss the issues raised in the media with people as we see them in clinic, regardless of whether they raise the issue themselves or not. This may help allay fears and enable them to make their own decisions. 

Shared decision-making
A major factor here is shared decision-making, which should be a routine element of all consultations. The Advancing Quality Alliance (AQuA, 2013) advocates encouraging people to ask three questions to enable them to make decisions about their care:

• What are my options?
• What are the pros and cons of each option for me?
• How do I get support to help me make a decision that is right for me? 

These questions may provide a good decision-making structure when dealing with enquiries about diabetes medications, whether incretin-based or otherwise, both now and in the future. 

In this education supplement Jen Nash explores the barriers to adherence and gives some examples of “conversation starters” to encourage people with diabetes to discuss their concerns. In addition, Julie Brake discusses how people with diabetes perceive risks associated with diabetes and how best to communicate risk. Both these articles are timely considering the recent media concerns about diabetes medications.