• James H Flory, Dominique Guelce, Crispin Goytia, Jing Li, Jea Young Min, Al Mushlin, Jeremy Orloff, and Victoria Mayer.
• Endocrinology Service, Department of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA. floryj@mskcc.org.
• J Gen Intern Med. 2023 May 1; 38 (6): 147614831476-1483.

BackgroundOver 5 million patients in the United States have type 2 diabetes mellitus (T2D) with chronic kidney disease (CKD); antidiabetic drug selection for this population is complex and has important implications for outcomes.ObjectiveTo better understand how providers choose antidiabetic drugs in T2D with CKD DESIGN: Mixed methods. Interviews with providers underwent qualitative analysis using grounded theory to identify themes related to antidiabetic drug prescribing. A provider survey used vignettes and direct questions to quantitatively assess prescribers' knowledge and preferences. A retrospective cohort analysis of real-world prescribing data assessed the external validity of the interview and survey findings.ParticipantsPrimary care physicians, endocrinologists, nurse-practitioners, and physicians' assistants were eligible for interviews; primary care physicians and endocrinologists were eligible for the survey; prescribing data were derived from adult patients with serum creatinine data.Main MeasuresInterviews were qualitative; for the survey and retrospective cohort, proportion of patients receiving metformin was the primary outcome.Key ResultsInterviews with 9 providers identified a theme of uncertainty about guidelines for prescribing antidiabetic drugs in patients with T2D and CKD. The survey had 105 respondents: 74 primary care providers and 31 endocrinologists. Metformin was the most common choice for patients with T2D and CKD. Compared to primary care providers, endocrinologists were less likely to prescribe metformin at levels of kidney function at which it is contraindicated and more likely to correctly answer a question about metformin's contraindications (71% versus 41%) (p < .05). Real-world data were consistent with survey findings, and further showed low rates of use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists (<10%) in patients with eGFR below 60 ml/min/1.73m2.ConclusionsProviders are unsure how to treat T2D with CKD and incompletely informed as to existing guidelines. This suggests opportunities to improve care.© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.

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