Last week, a Healthed survey of nearly 2000 GPs across the country showed that 55% agreed with the Government’s newly imposed restrictions on GLP-1 receptor agonists—compared with 45% who opposed them.
Dr Ralph Audehm, Clinical Associate Professor at the University of Melbourne’s Department of General Practice and a GP with 35 years of experience, is one of the 45% who do not think the new restrictions are in the best interest of patients – or the health budget either, for that matter.
Dr Audehm is “quite aghast,” that so many of his colleagues support the changes.
“The thing that angered me was it means that for some of my patients, who this would be the best medication for, I have to go through the whole hokey-pokey of putting someone on an SGLT2, and then I have to stop it and then start the GLP-1 RA, which is ridiculous,” Dr Audehm says.
Take a 45-year-old patient with type 2 diabetes and a BMI of 35, with an hbA1c > 8. At that age, cardiovascular risk would be quite small, and weight would be the biggest issue. In this case, an SGLT2 would likely not have a significant impact on their hba1c, but a GLP-1 RA would, he says.
But now such a patient must start on an SGLT2 inhibitor, wait three months to assess their blood glucose levels, then stop that drug and start the GLP-1 — meaning their diabetes won’t be as well-controlled in the interim and they may experience some side effects — not to mention the challenges of chopping and changing the medications, Dr Audehm adds.
“What this means is that we can no longer prescribe the best drug for the person in front of us. We have to do a dance,” he says. “People hate shifting medication, it just increases confusion.”
In fact:
“Doctors should have more authority to care for their patients the best way they can – we know our patients and the people making decisions have little idea,” one GP said.
In the survey, GPs who supported the restrictions tended to think they were necessary because of supply shortages—which may help explain the discrepancy.
That’s also the view of Professor Nial Wheate, an expert in pharmaceuticals at Macquarie University, who has previously argued that GLP-1s should not be PBS-funded for weight loss when the shortages resolve.
“We do already have drugs that we know to be safe, effective, and cost efficient for the treatment of type 2 diabetes and I understand, in the context of current shortages of GLP-1 drugs, why the TGA is directing doctors to prescribe those drugs as first line before they consider a GLP-1,” Professor Wheate explains.
The changes came after an independent review documented widespread use outside of the PBS restrictions, coupled with hefty costs.
In 2021-2022 GLP-1 RAs were the highest expenditure class of diabetes medications listed on the PBS, accounting for 26% of spending and totalling $194 million.
Several GPs felt the expensive price-tag on the drugs and the soaring demand do mean that prescribing needs to be reined in.
“The Government has a responsibility to manage funds, and if good control can be achieved with cheaper meds, it should be tried first,” one GP commented.
“There are limits to every budget. I consider that the government has a duty to spend tax-payers’ money as cost-effectively as possible,” said another.
“At this stage, there is a huge demand for GLP-1s for weight loss so, if the PBS listing was completely unconditional, the immediate effect would be a huge increase in cost providing the GLP-1s were available. At this stage, it is difficult to predict the long-term results…. As the drug is in short supply, we GPs have been prevented from prescribing it more widely. I think a lot more experience is needed,” another GP commented.
But some argue that reductions in heart disease and renal disease that may result from greater access to GLP-1 RAs would ultimately decrease costs in the long run—and improve patient care.
And they say the restrictions may actually be short-sighted given their capacity to reduce more costly complications down the road.
“One of the main reasons for choosing Ozempic over SGLT-2 inhibitors is offering a diabetic patient a good option to lose weight. This will lead to better control of diabetes. It will also improve their lipid, self-esteem, hypertension and decrease the risk of cardiovascular events. Obesity is a major risk for health and it’s probably contributed to having diabetes on the first place,” one surveyed GP told Healthed.
Dr Audehm agrees.
“I think they’re incredibly cost effective for managing diabetes,” he says. “We’ve known for a long time that the lower your A1c, for the longer, prevents long-term problems. Even a difference of 1% means significant reductions in retinopathy and nephropathy, and after about 10 years, a significant reduction in heart disease. So, we know lower A1c is good.”
“These drugs lower A1c enormously — they put them to almost normal levels of A1c. So, we know it’s going to reduce the impact of diabetes on the kidneys and their eyes.” Dr Audehm says.
Other benefits with GLP-1 RAs include improvements in arthritis, sleep apnoea, and CVD—along with delaying dialysis and keeping people in the workforce longer too, he adds.
“When people make these decisions, they make it from a commercial sort of lens, and they look at very short-term costs.”
“Diabetes is lifelong. It causes significant problems and health complications for people. And if we can intervene early for the right people, we’ll prevent a lot of that deterioration.”
“And the way the government policies are shaping is, even if there are better drugs that will prevent complications in the long run and may save us money, we don’t care. We’re only interested in the short-term costs year by year. And I think that’s the wrong attitude.”
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