Educating Medical Students on How to Prescribe Anti-Hyperglycaemic Drugs: A Practical Guide
Abstract
:1. Introduction
2. What to Teach
3. How to Teach
4. Conclusions and Future Direction
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- GBD 2021 Diabetes Collaborators. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: A systematic analysis for the Global Burden of Disease Study 2021. Lancet 2023, 402, 203–234. [Google Scholar] [CrossRef] [PubMed]
- Sun, H.; Saeedi, P.; Karuranga, S.; Pinkepank, M.; Ogurtsova, K.; Duncan, B.B.; Stein, C.; Basit, A.; Chan, J.C.N.; Mbanya, J.C.; et al. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res. Clin. Pract. 2022, 183, 109119. [Google Scholar] [CrossRef] [PubMed]
- World Obesity Federation. World Obesity Atlas. 2022. Available online: https://www.worldobesity.org/resources/resource-library/world-obesity-atlas-2022 (accessed on 14 August 2023).
- Leon, B.M.; Maddox, T.M. Diabetes and cardiovascular disease: Epidemiology, biological mechanisms, treatment recommendations and future research. World J. Diabetes 2015, 6, 1246–1258. [Google Scholar] [CrossRef] [PubMed]
- Bhupathiraju, S.N.; Hu, F.B. Epidemiology of Obesity and Diabetes and Their Cardiovascular Complications. Circ. Res. 2016, 118, 1723–1735. [Google Scholar] [CrossRef] [PubMed]
- Bommer, C.; Heesemann, E.; Sagalova, V.; Manne-Goehler, J.; Atun, R.; Bärnighausen, T.; Vollmer, S. The global economic burden of diabetes in adults aged 20-79 years: A cost-of-illness study. Lancet Diabetes Endocrinol. 2017, 5, 423–430. [Google Scholar] [CrossRef] [PubMed]
- Dornan, T.; Ashcroft, D.; Heathfield, H.; Lewis, P.; Miles, J.; Taylor, D.; Tully, M.; Wass, V. An in Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education. EQUIP Study. Available online: http://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf (accessed on 27 December 2009).
- Ryan, C.; Ross, S.; Davey, P.; Duncan, E.M.; Francis, J.J.; Fielding, S.; Johnston, M.; Ker, J.; Lee, A.J.; MacLeod, M.J.; et al. Prevalence and causes of prescribing errors: The PRescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) study. PLoS ONE 2014, 9, e79802. [Google Scholar] [CrossRef] [PubMed]
- Ashcroft, D.M.; Lewis, P.J.; Tully, M.P.; Farragher, T.M.; Taylor, D.; Wass, V.; Williams, S.D.; Dornan, T. Prevalence, Nature, Severity and Risk Factors for Prescribing Errors in Hospital Inpatients: Prospective Study in 20 UK Hospitals. Drug Saf. 2015, 38, 833–843. [Google Scholar] [CrossRef]
- Maxwell, S.R.; Cascorbi, I.; Orme, M.; Webb, D.J. Educating European (junior) doctors for safe prescribing. Basic Clin. Pharmacol. Toxicol. 2007, 101, 395–400. [Google Scholar] [CrossRef] [PubMed]
- Donker, E.M.; Brinkman, D.J.; van Rosse, F.; Janssen, B.; Knol, W.; Dumont, G.; Jorens, P.G.; Dupont, A.; Christiaens, T.; van Smeden, J.; et al. Do we become better prescribers after graduation: A 1-year international follow-up study among junior doctors. Br. J. Clin. Pharmacol. 2022, 88, 5218–5226. [Google Scholar] [CrossRef] [PubMed]
- Lewis, P.J.; Dornan, T.; Taylor, D.; Tully, M.P.; Wass, V.; Ashcroft, D.M. Prevalence, incidence and nature of prescribing errors in hospital inpatients: A systematic review. Drug Saf. 2009, 32, 379–389. [Google Scholar] [CrossRef]
- Tully, M.P.; Ashcroft, D.M.; Dornan, T.; Lewis, P.J.; Taylor, D.; Wass, V. The causes of and factors associated with prescribing errors in hospital inpatients: A systematic review. Drug Saf. 2009, 32, 819–836. [Google Scholar] [CrossRef]
- Farzi, S.; Irajpour, A.; Saghaei, M.; Ravaghi, H. Causes of Medication Errors in Intensive Care Units from the Perspective of Healthcare Professionals. J. Res. Pharm. Pract. 2017, 6, 158–165. [Google Scholar] [PubMed]
- Jansen, B.H.E.; Disselhorst, G.W.; Schutte, T.; Jansen, B.; Rissmann, R.; Richir, M.C.; Keijsers, C.; Vanmolkot, F.H.M.; van den Brink, A.M.; Kramers, C.; et al. Essential diseases in prescribing: A national Delphi study towards a core curriculum in pharmacotherapy education. Br. J. Clin. Pharmacol. 2018, 84, 2645–2650. [Google Scholar] [CrossRef] [PubMed]
- Belančić, A.; Sans-Pola, C.; Jouanjus, E.; Alcubilla, P.; Arellano, A.L.; Žunić, M.; Nogueiras-Álvarez, R.; Roncato, R.; Sáez-Peñataro, J. European association for clinical pharmacology and therapeutics young clinical pharmacologists working group: A cornerstone for the brighter future of clinical pharmacology. Eur. J. Clin. Pharmacol. 2022, 78, 691–694. [Google Scholar] [CrossRef] [PubMed]
- Davies, M.J.; Aroda, V.R.; Collins, B.S.; Gabbay, R.A.; Green, J.; Maruthur, N.M.; Rosas, S.E.; Del Prato, S.; Mathieu, C.; Mingrone, G.; et al. Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2022, 45, 2753–2786. [Google Scholar] [CrossRef]
- Visseren, F.L.J.; Mach, F.; Smulders, Y.M.; Carballo, D.; Koskinas, K.C.; Bäck, M.; Benetos, A.; Biffi, A.; Boavida, J.M.; Capodanno, D.; et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur. Heart J. 2021, 42, 3227–3337. [Google Scholar] [CrossRef] [PubMed]
- Lingvay, I.; Sumithran, P.; Cohen, R.V.; le Roux, C.W. Obesity management as a primary treatment goal for type 2 diabetes: Time to reframe the conversation. Lancet 2022, 399, 394–405. [Google Scholar] [CrossRef] [PubMed]
- Tamez-Pérez, H.E.; Quintanilla-Flores, D.L.; Rodríguez-Gutiérrez, R.; González-González, J.G.; Tamez-Peña, A.L. Steroid hyperglycemia: Prevalence, early detection and therapeutic recommendations: A narrative review. World J. Diabetes 2015, 6, 1073–1081. [Google Scholar] [CrossRef]
- Dungan, K.; Merrill, J.; Long, C.; Binkley, P. Effect of beta blocker use and type on hypoglycemia risk among hospitalized insulin requiring patients. Cardiovasc. Diabetol. 2019, 18, 163. [Google Scholar] [CrossRef]
- Williams, B.; Mancia, G.; Spiering, W.; Agabiti Rosei, E.; Azizi, M.; Burnier, M.; Clement, D.L.; Coca, A.; De Simone, G.; Dominiczak, A.; et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J. Hypertens. 2018, 36, 1953–2041. [Google Scholar]
- Mach, F.; Baigent, C.; Catapano, A.L.; Koskinas, K.C.; Casula, M.; Badimon, L.; Chapman, M.J.; De Backer, G.G.; Delgado, V.; Ference, B.A.; et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: Lipid modification to reduce cardiovascular risk. Eur. Heart J. 2020, 41, 111–188. [Google Scholar] [CrossRef] [PubMed]
- Zorginstituut Nederland. GIP Databank. 2020. Available online: https://www.gipdatabank.nl/ (accessed on 6 November 2023).
- Brinkman, D.J.; Tichelaar, J.; Okorie, M.; Bissell, L.; Christiaens, T.; Likic, R.; Maciulaitis, R.; Costa, J.; Sanz, E.J.; Tamba, B.I.; et al. Pharmacology and Therapeutics Education in the European Union Needs Harmonization and Modernization: A Cross-sectional Survey Among 185 Medical Schools in 27 Countries. Clin. Pharmacol. Ther. 2017, 102, 815–822. [Google Scholar] [CrossRef] [PubMed]
- Brinkman, D.J.; Monteiro, T.; Monteiro, E.C.; Richir, M.C.; van Agtmael, M.A.; Tichelaar, J. Switching from a traditional undergraduate programme in (clinical) pharmacology and therapeutics to a problem-based learning programme. Eur. J. Clin. Pharmacol. 2021, 77, 421–429. [Google Scholar] [CrossRef] [PubMed]
- Brinkman, D.J.; Tichelaar, J.; Schutte, T.; Benemei, S.; Bottiger, Y.; Chamontin, B.; Christiaens, T.; Likic, R.; Ma iulaitis, R.; Marandi, T.; et al. Essential competencies in prescribing: A first european cross-sectional study among 895 final-year medical students. Clin. Pharmacol. Ther. 2017, 101, 281–289. [Google Scholar] [CrossRef] [PubMed]
- De Vries, T.P.G.M.; Henning, R.H.; Hogerzeil, H.V.; Bapna, J.S.; Bero, L.; Kafle, K.K.; Mabadeje, A.F.B.; Santoso, B.; Smith, A.J. Impact of a short course in pharmacotherapy for undergraduate medical students: An international randomised controlled study. Lancet 1995, 346, 1454–1457. [Google Scholar] [CrossRef] [PubMed]
- Smith, A.; Hill, S.; Walkom, E.; Thambiran, M. An evaluation of the World Health Organization problem-based pharmacotherapy teaching courses (based on the “Guide to Good Prescribing”), 1994–2001. Eur. J. Clin. Pharmacol. 2005, 61, 785–786. [Google Scholar] [CrossRef] [PubMed]
- Kamarudin, G.; Penm, J.; Chaar, B.; Moles, R. Educational interventions to improve prescribing competency: A systematic review. BMJ Open 2013, 3, e003291. [Google Scholar] [CrossRef] [PubMed]
- Omer, U.; Danopoulos, E.; Veysey, M.; Crampton, P.; Finn, G. A Rapid Review of Prescribing Education Interventions. Med. Sci. Educ. 2021, 31, 273–289. [Google Scholar] [CrossRef]
- Ross, S.; Loke, Y.K. Do educational interventions improve prescribing by medical students and junior doctors? A systematic review. Br. J. Clin. Pharmacol. 2009, 67, 662–670. [Google Scholar] [CrossRef]
- Tichelaar, J.; Richir, M.C.; Garner, S.; Hogerzeil, H.; de Vries, T.P.G.M. WHO guide to good prescribing is 25 years old: Quo vadis? Eur. J. Clin. Pharmacol. 2020, 76, 507–513. [Google Scholar] [CrossRef]
- Hmelo-Silver, C.E. Problem-Based Learning: What and How Do Students Learn? Educ. Psychol. Rev. 2004, 16, 235–266. [Google Scholar] [CrossRef]
- Dolmans, D.; Michaelsen, L.; van Merriënboer, J.; van der Vleuten, C. Should we choose between problem-based learning and team-based learning? No, combine the best of both worlds! Med. Teachnol. 2015, 37, 354–359. [Google Scholar] [CrossRef] [PubMed]
- Bakkum, M.J.; Richir, M.C.; Papaioannidou, P.; Likic, R.; Sanz, E.J.; Christiaens, T.; Costa, J.N.; Mačiulaitis, R.; Dima, L.; Coleman, J.; et al. EurOP(2)E—The European Open Platform for Prescribing Education, a consensus study among clinical pharmacology and therapeutics teachers. Eur. J. Clin. Pharmacol. 2021, 77, 1209–1218. [Google Scholar] [CrossRef] [PubMed]
- Godden, D.R.; Baddeley, A.D. Context-dependent memory in two natural environments: On land and underwater. Br. J. Psychol. 1975, 66, 325–331. [Google Scholar] [CrossRef]
- Tichelaar, J.; van Kan, C.; van Unen, R.J.; Schneider, A.J.; van Agtmael, M.A.; de Vries, T.P.; Richir, M.C. The effect of different levels of realism of context learning on the prescribing competencies of medical students during the clinical clerkship in internal medicine: An exploratory study. Eur. J. Clin. Pharmacol. 2015, 71, 237–242. [Google Scholar] [CrossRef] [PubMed]
- Dekker, R.S.; Schutte, T.; Tichelaar, J.; Thijs, A.; van Agtmael, M.A.; de Vries, T.P.; Richir, M.C. A novel approach to teaching pharmacotherapeutics--feasibility of the learner-centered student-run clinic. Eur. J. Clin. Pharmacol. 2015, 71, 1381–1387. [Google Scholar] [CrossRef] [PubMed]
- Schutte, T.; Tichelaar, J.; van Agtmael, M. Learning to prescribe in a student-run clinic. Med. Teachnol. 2016, 38, 425. [Google Scholar] [CrossRef]
- Reumerman, M.O.; Richir, M.C.; Sultan, R.; Daelmans, H.E.M.; Springer, H.; Grijmans, E.; Muller, M.; van Agtmael, M.A.; Tichelaar, J. An inter-professional student-run medication review programme. Reducing adverse drug reactions in a memory outpatient clinic: A controlled clinical trial. Expert Opin. Drug Saf. 2022, 21, 1511–1520. [Google Scholar] [CrossRef]
- Reumerman, M.O.; Tichelaar, J.; Richir, M.C.; van Agtmael, M.A. Medical students as junior adverse drug event managers facilitating reporting of ADRs. Br. J. Clin. Pharmacol. 2021, 87, 4853–4860. [Google Scholar] [CrossRef]
- Schutte, T.; Prince, K.; Richir, M.; Donker, E.; van Gastel, L.; Bastiaans, F.; de Vries, H.; Tichelaar, J.; van Agtmael, M. Opportunities for Students to Prescribe: An Evaluation of 185 Consultations in the Student-run Cardiovascular Risk Management Programme. Basic Clin. Pharmacol. 2018, 122, 299–302. [Google Scholar] [CrossRef]
- Sultan, R.; van den Beukel, T.O.; Reumerman, M.O.; Daelmans, H.E.M.; Springer, H.; Grijmans, E.; Muller, M.; Richir, M.C.; van Agtmael, M.A.; Tichelaar, J. An Interprofessional Student-Run Medication Review Program: The Clinical STOPP/START-Based Outcomes of a Controlled Clinical Trial in a Geriatric Outpatient Clinic. Clin. Pharmacol. Ther. 2022, 111, 931–938. [Google Scholar] [CrossRef] [PubMed]
- Cohen, J. Eight steps for starting a student-run clinic. JAMA 1995, 273, 434–435. [Google Scholar] [CrossRef] [PubMed]
- Smith, S.; Thomas, R., 3rd; Cruz, M.; Griggs, R.; Moscato, B.; Ferrara, A. Presence and characteristics of student-run free clinics in medical schools. JAMA 2014, 312, 2407–2410. [Google Scholar] [CrossRef] [PubMed]
- An, M.L.; Laks, K.M.; Long, N.A. Uninsured with Diabetes: How Student-Run Free Medical Clinics Are Filling the Gap. Clin. Diabetes 2019, 37, 282–283. [Google Scholar] [CrossRef] [PubMed]
- Schroeder, M.N.; Hickey, M.O. Patient Satisfaction with Diabetes Care in a Student-Run Free Medical Clinic: A Quality Improvement Study. J. Pharm. Technol. 2020, 36, 61–67. [Google Scholar] [CrossRef] [PubMed]
- Donker, E.M.; Brinkman, D.J.; Richir, M.C.; Papaioannidou, P.; Likic, R.; Sanz, E.J.; Christiaens, T.; Costa, J.N.; De Ponti, F.; Böttiger, Y.; et al. The European Prescribing Exam: Assessing whether European medical students can prescribe rationally and safely. Eur. J. Clin. Pharmacol. 2022, 78, 1049–1051. [Google Scholar] [CrossRef] [PubMed]
- Harden, R.M.; Stevenson, M.; Downie, W.W.; Wilson, G.M. Assessment of clinical competence using objective structured examination. Br. Med. J. 1975, 1, 447–451. [Google Scholar] [CrossRef]
- Khan, K.Z.; Ramachandran, S.; Gaunt, K.; Pushkar, P. The Objective Structured Clinical Examination (OSCE): AMEE Guide No. 81. Part I: An historical and theoretical perspective. Med. Teachnol. 2013, 35, e1437–e1446. [Google Scholar] [CrossRef]
Anti-Hyperglycaemic Class | Pharmacodynamics | Efficacy * | Safety Profile ** | Hypoglycaemic Risk | Weight Change *** | Potential Cardio-Renal Benefits | Contraindications/Special Considerations | Costs |
---|---|---|---|---|---|---|---|---|
Biguanides | - Inhibition of gluconeogenesis and glycogenolysis - Increase in insulin sensitivity - Delay in the absorption of glucose in the small intestine | ++ | - GI ADRs - Lactic acidosis | Low | ↔ | MACE: potential benefit | - Acute metabolic acidosis - eGFR < 30 mL/min - Decompensated heart failure, recent myocardial infarction, shock - Hepatic insufficiency | Low |
Thiazolidinediones **** | - PPAR-γ activation | ++ | - Oedema - Congestive heart failure - Hepatogram alteration | Low | ↑ | MACE: potential benefit HF: increased risk | - (History of) heart failure - Hepatic insufficiency - Existing or recovered bladder cancer | Low |
α-gluconidase inhibitors | - Inhibition of intestinal α-glucosidase | + | - GI ADRs | Low | ↔ | Neutral | - Inflammatory bowel disease - Colon ulceration - Partial bowel obstruction - Hepatic insufficiency - eGFR <30 mL/min | Low |
Sulfonylurea derivates | - β-cytotropic drugs (glucose-independent stimulation) | ++ | - Hypoglycaemia - GI ADRs - Skin and subcutaneous tissue disorders | High | ↑ | Neutral | - C-peptide negative DM - Hepatic insufficiency - Severe impairment of renal function (≥G3b); does not apply for gliquidone (dose adjustment per renal function not needed) | Low |
Glinides | - β-cytotropic drugs (glucose-independent stimulation) | ++ | - Hypoglycaemia - GI ADRs | Intermediate | ↑ | Neutral | - C-peptide-negative DM - Hepatic insufficiency | Low |
SGLT2 inhibitors | - Competitive inhibition of SGLT2; renal mechanism | +(+) | - Urinary tract infection - Genital infection - Polyuria, pollakisuria, volume depletion - Euglycaemic ketoacidosis (rare) - Fournier gangrene (extremely rare) | Low | ↓ | MACE: benefit for canagliflozin and empagliflozin HF: benefit for dapagliflozin and empagliflozin DKD: benefit for canagliflozin, dapagliflozin and empagliflozin | - Recurrent urinary infections Considerations: - Euglycaemic ketoacidosis (rare) - Fournier gangrene (extremely rare) | High |
DPP-4 inhibitors | - β-cytotropic drugs (glucose-dependent stimulation); - ↑insulin/glucagon ratio | + | - Very good safety profile and tolerability - ADRs are occasional and not typical | No | ↔ | HF: potential risk of saxaglitptin | - Consider discontinuation in case of acute pancreatitis | High |
GLP-1 receptor agonists | - β-cytotropic drugs (glucose-dependent stimulation); - ↑insulin/glucagon ratio | ++(+) | - GI ADRs | No | ↓(↓) | MACE: benefit for dulaglutide, liraglutide and semaglutide DKD: potential benefit for dulaglutide, liraglutide, and semaglutide (secondary outcomes) | - Gastroparesis - Consider discontinuation in case of acute pancreatitis | High |
Insulin (human and analogues) | - Tyrosine kinase receptor activation | ++(+) | - Hypoglycaemia - Lipodystrophy - Somogyi effect - Injection site reactions | High | ↑ | Neutral | - Injection site reactions - Higher risk of hypoglycaemia with human insulin vs. analogues | High |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Donker, E.M.; Belančić, A.; Piët, J.D.; Vitezić, D.; Tichelaar, J.; on behalf of the Clinical Pharmacology and Therapeutics Teach the Teacher (CP4T) Program and the Early Career Pharmacologists of the European Association for Clinical Pharmacology and Therapeutics (EACPT). Educating Medical Students on How to Prescribe Anti-Hyperglycaemic Drugs: A Practical Guide. Diabetology 2023, 4, 499-506. https://doi.org/10.3390/diabetology4040043
Donker EM, Belančić A, Piët JD, Vitezić D, Tichelaar J, on behalf of the Clinical Pharmacology and Therapeutics Teach the Teacher (CP4T) Program and the Early Career Pharmacologists of the European Association for Clinical Pharmacology and Therapeutics (EACPT). Educating Medical Students on How to Prescribe Anti-Hyperglycaemic Drugs: A Practical Guide. Diabetology. 2023; 4(4):499-506. https://doi.org/10.3390/diabetology4040043
Chicago/Turabian StyleDonker, Erik M., Andrej Belančić, Joost D. Piët, Dinko Vitezić, Jelle Tichelaar, and on behalf of the Clinical Pharmacology and Therapeutics Teach the Teacher (CP4T) Program and the Early Career Pharmacologists of the European Association for Clinical Pharmacology and Therapeutics (EACPT). 2023. "Educating Medical Students on How to Prescribe Anti-Hyperglycaemic Drugs: A Practical Guide" Diabetology 4, no. 4: 499-506. https://doi.org/10.3390/diabetology4040043
APA StyleDonker, E. M., Belančić, A., Piët, J. D., Vitezić, D., Tichelaar, J., & on behalf of the Clinical Pharmacology and Therapeutics Teach the Teacher (CP4T) Program and the Early Career Pharmacologists of the European Association for Clinical Pharmacology and Therapeutics (EACPT). (2023). Educating Medical Students on How to Prescribe Anti-Hyperglycaemic Drugs: A Practical Guide. Diabetology, 4(4), 499-506. https://doi.org/10.3390/diabetology4040043