Factors Influencing Physician Hesitancy to Prescribe SGLT2 Inhibitors for Type 2 Diabetes PDF

ARTICLE The factors influencing physicians' hesitancy to prescribe Sodium-glucose co-transporter two inhibitors for managing type 2 diabetes mellitus - A Systematic Review Abstract: Type 2 diabetes mellitus (T2DM) and its complications are a global health concern and the leading cause o...

ARTICLE The factors influencing physicians' hesitancy to prescribe Sodium-glucose co-transporter two inhibitors for managing type 2 diabetes mellitus - A Systematic Review Abstract: Type 2 diabetes mellitus (T2DM) and its complications are a global health concern and the leading cause of death. Recent scientific advances have made available novel methods of controlling high blood sugar levels and the complications of T2DM. Among these, sodium-glucose cotransporter-2 inhibitors (SGLT2-i) stand out as a group of seven drugs that provide new horizons in managing T2DM and associated kidney and Cardiovascular system (CVS) ailments. Despite the substantial evidence supporting their efficacy, the prescription rates of SGLT2 inhibitors still remains low and need to be higher, mainly due to physician hesitancy, among other considerations. This research project examined the factors influencing physician hesitancy in prescribing SGLT2 inhibitors to treat T2DM. Removing these hesitancies and knowing its benefits among clinicians will increase confidence in prescribing SGLT2 inhibitors, which are beneficial in managing T2DM and other DM-related complications and significantly improve patient care. Its benefits far exceed any side effects, which are easily manageable by clinicians' training. Objective: The systematic review aims to evaluate the barriers associated with physicians' hesitation in prescribing SGLT2 inhibitors and strategies to reduce them. The plan to identify and synthesise factors influencing physician hesitancy for prescribing SGLT-2inhibitors in the management of T2DM, Methods: This systematic review aims to synthesise the existing literature on the factors contributing to this hesitancy. Results: Key barriers identified include concerns about adverse effects, limited physician experience and knowledge, patient-related factors, economic considerations, and systemic healthcare barriers.) Conclusions: Understanding and addressing these factors is essential to optimise the use of SGLT2 inhibitors in clinical practice in T2DM patients and improve patient outcomes. Keywords: Keywords used in search of the systematic review included "type 2 diabetes," "SGLT2 inhibitors," "physician hesitancy," and "prescribing uptake.” Introduction: Type 2 diabetes mellitus (T2DM) is a chronic, progressive disease characterised by insulin resistance and pancreatic beta-cell dysfunction, leading to hyperglycaemia. The global burden of T2DM is significant, with an increasing prevalence that poses substantial challenges to healthcare systems. T2DM affects an estimated 462 million people globally and 4.3 million in the UK, ranking it as the ninth-leading cause of mortality (Overview | Type 2 diabetes in adults: management | Guidance | NICE, 2015; Campbell et al., 2023; Young et al., 2023). T2DM increases patient’s risk of cardiovascular, metabolic and renal complications. Effective management of T2DM involves not only glycemic control but also the prevention of cardiovascular and renal complications, which are significant causes of morbidity and mortality in these patients (Anker et al., 2021; Hinton et al., 2021). SGLT2 inhibitors, a novel class of oral antidiabetic drugs, have significantly reduced hyperglycaemia cardiovascular events, improved renal outcomes, and provided modest weight loss in patients with T2DM (Neal et al., 2017; Wiviott et al., 2019). Despite these benefits, physicians have considerable hesitancy in prescribing SGLT2 inhibitors. Understanding the reasons behind this hesitancy is critical for improving the adoption of these drugs in clinical practice. This systematic review seeks to identify and analyse the factors contributing to physicians’ hesitancy in prescribing SGLT2 inhibitors for managing T2DM. By synthesising data from various studies, this review provides a comprehensive overview of the barriers to prescribing SGLT2 inhibitors and suggests potential strategies to overcome these challenges. T2DM results: SGLT2 inhibitors are a recently introduced group of medications with a unique mode of action. They excrete excessive blood glucose through the kidneys, a function not shared by other diabetes medications. This novel approach has shown evidence-based improvements in 90% of diagnosed T2DM cases. It lowers blood glucose levels, benefits CVS and renal functions, and helps reduce weight (Overview | Type 2 diabetes in adults: management | Guidance | NICE, 2015; Seery, 2019; Glover et al., 2022). In addition, the SGLT2 inhibitors are also used in CVS, renal failure and low eGFR cases where other medications are contraindicated (Madaan, Akhtar and Najmi, 2016; Glover et al., 2022). Most national and international health guidelines have recommended using SGLT2 inhibitors with or without other medications to manage T2DM and reduce DM-related complications (Overview | Type 2 diabetes in adults: management | Guidance | NICE, 2015; Campbell et al., 2023; Young et al., 2023). The preliminary literature review demonstrates that despite robust evidence about benefits, clinicians have common factors influencing physicians' hesitancy in prescribing SGLT2 inhibitors for T2DM management (Milder et al., 2021; Sangha et al., 2021).. A systematic review synthesises existing research to identify and understand the factors influencing physicians' hesitancy in initiating SGLT2 inhibitors in managing T2DM. My research aims to study and explore the barriers and concerns associated with reducing physicians' hesitation in prescribing SGLT2 inhibitors, which can potentially improve the management of T2DM. This study identifies the factors influencing the hesitancy of physicians to prescribe SGLT2i, the perceived potential impacts towards medication adherence, and enhances the interventions to overcome the identified factors. This study aims to recognise the factors of hesitancy in prescribing SGLT2i for T2DM management among physicians and to determine the frequently perceived challenges and their correlations with treatment adherence. The study aims to identify factors influencing physicians' hesitancy in prescribing SGLT2 inhibitors for managing T2DM. The rationale is to understand the factors that affect the decision-making process and confidence level of physicians regarding prescribing SGLT2 inhibitors. Exploring hesitancy in prescribing can help develop strategies to improve the initiation of SGLT2 inhibitors in clinical practice (Hinton et al., 2021; Wilding et al., 2022; evaluate barriers in initiating sglt2 for treating t2dm from clinicians and patients perspectives - Google Search, no date). The research looked for and analysed studies and articles that explored factors such as lack of awareness, concerns about side effects, and scepticism about effectiveness (Milder et al., 2021; Wilding et al., 2022; Yi et al., 2024). The research has shown that some mitigating factors could be the training, education, and updated guidelines that can help increase the use of SGLT2 inhibitors. The look in-depth at these aspects, which could help rationalise the prescribing patterns of SGLT2 inhibitors (‘The evolving role of SGLT2 inhibitors - DiabetesontheNet’, 2022; Yang et al., 2023). The evidence from the findings is valuable in improving practice and finding appropriate use of SGLT2 inhibitors. The project is related to my daily work in a GP surgery with diabetic patients and is also relevant to my studies and clinical practice. Synthesise the findings into a well-structured essay that comprehensively understands the topic (Seery, 2019; Hinton et al., 2021; Wilding et al., 2022; Young et al., 2023). The study's findings, which are an effort, can be disseminated widely to benefit medical practices. This publication will mark the initial stage of future research endeavours, and valuable insights and feedback will be crucial in shaping the direction of this research. Project Design and Methods: Moher D et al. research methodology framework used a systematic review. The systematic review steps were systematically described (PRISMA-P Group et al., 2015; Tawfik et al., 2019). Study design: A systematic review was conducted as part of this study. In this review, the search for relevant published studies on physician hesitancy to prescribe SGLT2 inhibitors selected and extracted data, analysed and critically examined the findings, summarised interpretations, and synthesised evidence-based conclusions (Tawfik et al., 2019). Methods: Describe the search strategy, inclusion and exclusion criteria, and analysis methods used to synthesise the data. Search Strategy: A comprehensive search strategy was developed to identify relevant studies by searching medical databases with applied medical subject headings (MeSH) in the following databases: PubMed, MEDLINE, Embase, and NIHR for studies, reviews, and clinical guidelines. The search was limited to studies published between January 2010 and October 2024, considering the relatively recent introduction of SGLT2 inhibitors into clinical practice. Keywords used in the search included "SGLT2 inhibitors," "physician hesitancy," "prescribing barriers," "type 2 diabetes, " Inclusion and Exclusion Criteria: Study Selection: Selected studies and articles within various databases used a set of inclusion and exclusion criteria linked to our research aims and questions. The inclusion criteria may specify the types of studies (e.g., population-based cohort, Longitudinal and cross-sectional, randomised control trials.) and the relevance to hesitancy in initiating SGLT2 inhibitors for treating type 2 diabetes mellitus from physicians' perspectives (Tawfik et al., 2019). Screening: The Screening process for selected studies from our search. There are two steps: The first has only screened the article title and abstract. The second step is to screen the studies to ensure they have full text relevant to the research questions. Next, we exclude and identify the duplicate data. Screening strategies are used for eligibility criteria to choose the studies pertinent to get the answer to the proposal question by using the inclusion and exclusion method, where the studies are included and excluded according to the proposal question. Eligibility, inclusion & exclusion criteria: Inclusion Criteria: Studies were included in this review if they met the following criteria: Observational studies (population-based cohort, Longitudinal and cross-sectional), randomised control trials. Studies conducted in the English language. Studies were conducted in adults over 18 years with the diagnosis of T2DM. Studies completed in the last ten years since SGLT2i came into clinical guidelines. Studies are clear and have relevant information according to the proposal question, and full text is available. Exclusion Criteria: Studies were excluded if they focused on patient perspectives rather than physician perspectives and were non-original research (e.g., reviews, editorials). Studies with no full text containing the information for SGLT2i use have not discussed the hesitancy in initiating prescriptions from practitioners, uptake from the patients’ side, and duplication. Studies not completed and published in English. Studies have not matched specified quality standards. Abstract of oral or poster presentation at the conference, reviews articles, reports, and editorial, identify any common bias in studies, books, and letters (Tawfik et al., 2019). Included: Primary research studies are summarised and documented according to the PRISMA flow chart (PRISMA-P Group et al., 2015). Data Extraction and Synthesis: Data Extraction: Focused on extracting data related to physician hesitancy. Data Extraction: The data extraction process is linked to the research question and aims. Systematically extract relevant information from the included studies. It may consist of details such as study characteristics, participant demographics, hesitancy factors, and perspectives from physicians regarding the initiation of SGLT2 inhibitors. The selected articles, exported from the Zotero referencing software manager, store the data on an Excel sheet, and the extracted data is using tables and charts with the results. Data were extracted from the included studies using a standardised form, capturing study characteristics (e.g., country, sample size, study design), the identified barriers to prescribing SGLT2 inhibitors, and any suggested strategies to address these barriers. Analysis synthesised the data, identifying recurring factors across studies. Quality Assessment: This assessment assessed the quality of the included studies and the potential risk of biases. It involved using CASP tools and criteria to evaluate the methodological quality and reliability of the included studies (Critical Appraisal tools, no date). CASP Checklist:10 questions to help make of a Systematic Review (Critical Appraisal tools, no date) Three broad issues to be considered appraising a systematic review study: Section A: Are the results of the review valid? 1- Did the review address clearly focused questions? YES Can’t Tell No Comment: I. Factors influencing physicians' hesitation 2- Did the author look for the right type of paper? YES Can’t Tell No Comment: Primary research papers 3- Do you think all the important, relevant studies were included? YES Can’t Tell No Comments: A. Factors of the reluctance of physicians to prescribe SGLT2 inhibitor B. Identification of primary barriers to prescribing SGLT2 inhibitors 4- Did the review’s authors do enough to assess the quality of the included studies? YES Can’t Tell No Comments: The assessment assessed the quality of the transparent primary research studies, which did not find the risk of biases. 5. If the review results have been combined, was it reasonable to do so? YES Can’t Tell No  Section B: What are the results? 6. What are the overall results of the review/ Comments: An overview of the main ideas and their future implications: 7. How precise are the results? Comments: Vital component of ongoing medical education and training. Engaging healthcare providers in discussions about their concerns. Enhancing training and education to bolster physicians' confidence Section C: Will the results help locally? Comments: Strategies overcome the challenges and Simplify clinical guidelines 8. Can the results be applied to the local population? YES Can’t Tell No Comments: Importance of continuous medical education, particularly in primary care environments, and updated clinical guidelines 9. Were all important outcomes considered? YES Can’t Tell No Comments: A multimodal intervention must address physicians' hesitancy in prescribing SGLT2 inhibitors. Ongoing medical education, training courses, and conversations with healthcare practitioners can help customise treatments to target specific adoption obstacles. 10. Are the benefits worth the harms and costs? YES Can’t Tell No Comments: Strategies can be employed to overcome these obstacles, including strengthened education and training, patient-centred methods, and simplified clinical guidelines. (Critical Appraisal tools, no date) Data Synthesis and Analysis: Analysed and synthesised the findings from the included studies and identified factors contributing to hesitancy in initiating SGLT2 inhibitors from physicians' perspectives. It involved observational studies (population-based cohort, Longitudinal and cross-sectional) and randomised control trials. It organised and combined the relevant data from selected studies and synthesised pertinent information. In the context of the research question, a comprehensive report summarised the findings, implications, limitations, gaps, challenges, and recommendations based on synthesising evidence related to the factors contributing to hesitancy in initiating SGLT2 inhibitors from physicians' perspectives. The study's results inform the results, discussions, limitations, and conclusions. Results: Physicians' reluctance to prescribe SGLT2 inhibitors stems from concerns regarding side effects, lack of expertise, patient-specific issues, economic considerations, systemic healthcare limitations, and the impact of clinical guidelines and evidence. These factors create challenging decisions for physicians when determining the most appropriate treatment for their patients. 1. Concerns about side effects of SGLT2-i Physicians express reluctance due to specific side effects of SGLT2 inhibitors, such as fractures, genital mycotic infections, urinary tract infections, Fournier's Gangrene, diabetic ketoacidosis (DKA), and volume depletion. These concerns significantly impact physicians' decision-making, especially in vulnerable patient populations (Anker et al., 2021; Jabbour, Ibrahim and Argyropoulos, 2022; Khunti et al., 2022; Campbell et al., 2023). 1.1 Urinary tract infections (UTIs) and genital infections Increased risks of UTIs, genital infections, and Fournier's Gangrene associated with SGLT2 inhibitors contribute to physicians' hesitancy in prescribing these medications, particularly for susceptible patients. Although genital mycotic infections can be treated with anti-fungal medications, continuous re-infection can lead to complications and even anti-microbial resistance. Fournier’s Gangrene, on the other hand, is a significantly damaging condition. It has been reported in SGLT2-i users, emphasising the need for physician awareness and patient education regarding infection risks (Jabbour, Ibrahim and Argyropoulos, 2022). 1.2 Diabetic Ketoacidosis (DKA) Physicians are cautious about the risk of euglycemic DKA associated with SGLT2 inhibitors, especially in patients with low insulin reserves. The potential for DKA remains a primary concern for physicians (American Diabetes Association, 2019; Jabbour, Ibrahim and Argyropoulos, 2022; Khunti et al., 2022). The possibility of diabetic ketoacidosis (DKA), a dangerous and sometimes fatal illness, is another significant safety issue. Despite being modest in absolute terms, people on SGLT2 inhibitors have a greater risk than those taking other drugs that decrease blood sugar. About half of doctors were worried about diabetic ketoacidosis (DKA), especially in patients who were on a low-carb diet or had low insulin reserves (Jabbour, Ibrahim and Argyropoulos, 2022; Forbes et al., 2024; Neuen et al., 2024). A "sick-day" strategy is recommended for temporarily discontinuing SGLT-2i therapy during acute illnesses or before surgeries to minimise the risk of DKA (Neuen et al., 2024). 1.3 Acute Kidney Injury (AKI) While the incidence of acute kidney injury with SGLT2 inhibitors is low, physicians emphasise the importance of regular renal function assessment, especially for patients with chronic kidney disease (CKD) (Jeong et al., 2021; Neuen et al., 2024). 1.4 Volume Depletion and Hypotension Concerns about volume depletion and hypotension due to the diuretic effects of these medications raise apprehensions, especially in older patients and those using antihypertensive medications. Patients placed on SGLT2-i should be aware of the importance of monitoring hydration status, particularly during acute illnesses and dietary restrictions (Sangha et al., 2021; Jabbour, Ibrahim and Argyropoulos, 2022). 1.5 Risk of lower limb Amputation Physicians consider the risk of diabetic foot leading to ischaemic damage when prescribing SGLT2 inhibitors, particularly for patients with a history of amputation or peripheral artery disease. Regular monitoring and foot care are essential to prevent complications (Neal et al., 2017; Anker et al., 2021; Sangha et al., 2021; Yang et al., 2023). 1.6 Risk of bone Fractures The ambiguity surrounding the potential connection between SGLT2 inhibitors and an increased risk of fractures influences physicians' decision-making, especially when treating patients with osteoporosis or other bone-related issues (Neal et al., 2017; Sangha et al., 2021; Campbell et al., 2023; Yang et al., 2023). 2 Lack of Knowledge and Experience Physicians' limited experience and confidence in prescribing SGLT2 inhibitors contribute to their reluctance. Understanding gaps in knowledge, uncertainty about long-term results, and rapid changes in therapeutic recommendations also weigh on physicians' decision-making (Overview | Type 2 diabetes in adults: management | Guidance | NICE, 2015; Sangha et al., 2021; Khunti et al., 2022; Young et al., 2023). 2.1 Not Knowing Much About SGLT2 Inhibitors and Insufficient Familiarity Medical professionals, particularly those in primary care settings, express limited familiarity with SGLT2 inhibitors. The lack of experience with these medications contributes to hesitancy in prescribing them (Khunti et al., 2022; Campbell et al., 2023). 2.2 Lack of Confidence Regarding Extended Results Physicians are still determining the long-term efficacy and safety of SGLT2 inhibitors, especially when considering patients requiring long-term therapy. This uncertainty adds to their hesitation in prescribing these medications (Jabbour, Ibrahim and Argyropoulos, 2022; Neuen et al., 2024; Yi et al., 2024). 2.3 Uncertainty Regarding Policies The rapid changes in therapeutic recommendations around SGLT2 inhibitors have exacerbated confusion among medical professionals, making it challenging to stay updated with guidelines (Jabbour, Ibrahim and Argyropoulos, 2022; Neuen et al., 2024; Yi et al., 2024). 2.4 Gaps in Education There is a noted need for more extensive continuous medical education (CME) programs focused on SGLT2 inhibitors to enhance physicians' proficiency in prescribing and managing these medications' adverse effects (Khunti et al., 2022; Young et al., 2023). 2.5 Limited or lack of Education and Training Physicians express the need for more thorough, continuous CME programs centred on SGLT2 inhibitors to improve their confidence in prescribing and understanding these medications' long-term benefits (Jabbour, Ibrahim and Argyropoulos, 2022; Korayem et al., 2022). 3. Patient-Specific Issues Physicians consider patients' age, comorbidities, medication adherence, and socioeconomic factors when prescribing SGLT2 inhibitors. These individual characteristics significantly influence treatment decisions, especially concerning the risk of side effects and the effectiveness of the medications. Patients may also decide against being placed on this medication (Sangha et al., 2021; Khunti et al., 2022; Forbes et al., 2024). 3.1 The Comorbidities and Age Physicians exhibit hesitancy in prescribing SGLT2 inhibitors to older patients or those with multiple comorbidities due to the increased risk of side effects associated with these medications. SGLT2 inhibitors increase the risk of side effects such as dehydration, renal impairment, CVS, and DKA; physicians are typically hesitant to prescribe them to older patients or patients with comorbidities (Neal et al., 2017; Korayem et al., 2022; Campbell et al., 2023; Neuen et al., 2024). A patient's age and comorbidities significantly influence the prescription of SGLT2 inhibitors. Due to the increased risk of side effects such as volume depletion and fractures, doctors are frequently reluctant to offer these medications to older patients. Furthermore, people with several comorbidities would experience more medication interactions and consequences (Hinton et al., 2021; Jeong et al., 2021; Campbell et al., 2023; Young et al., 2023). 3.2 Adherence to Medication Patients’ adherence to SGLT2 inhibitors influences physicians' concerns about prescribing SGLT2-i. The dosage and management of side effects impact physicians' decision-making about these medications (Campbell et al., 2023; Yang et al., 2023). 3.3 Medication Compliance Physicians are concerned that patients with a history of poor adherence may not fully benefit from SGLT2 inhibitors, leading them to consider alternative medications with better adherence profiles (Yang et al., 2023). 3.4 Patient Preferences and Health Literacy Patients' preferences and health literacy significantly influence physicians' prescribing behaviours, where low literacy and non-compliance concerns lead to alternative treatment choices (Campbell et al., 2023; Yang et al., 2023; Neuen et al., 2024). 4. Financial Aspects The price of SGLT2 inhibitors is a significant deterrent to their general use. 4.1 Economic Considerations The cost of SGLT2 inhibitors deters their widespread use. These medications are often more expensive than alternative treatments for glucose management, and physicians may be hesitant to prescribe them due to financial constraints (Glover et al., 2022; Khunti et al., 2022). 5. Systemic Healthcare Limitations The project has identified systemic reasons for the hesitancy to prescribe SGLT2 inhibitors in the healthcare setting. Issues such as inadequate healthcare infrastructure, limited access to endocrinologists and diabetes experts, institutional guidelines, and the quality of healthcare system assistance contribute to physicians' reluctance to prescribe SGLT2 inhibitors. These systemic obstacles hinder the effectively utilisation of these medications (Glover et al., 2022; Chonko et al., 2023). 5-1 Infrastructure for Healthcare Inadequate healthcare infrastructure, especially in remote or underdeveloped places, has been shown to hamper the use of SGLT2 inhibitors. Doctors working in these environments reported needing help accessing the monitoring resources, specialised consultations, and diagnostic tools required to treat and maintain patients on SGLT2 inhibitors appropriately (Madaan, Akhtar and Najmi, 2016, 2016; Newman, 2020). 5-2 Expert Assistance Access issues to endocrinologists and other diabetes experts have been identified as a significant barrier. The decrease in the use of SGLT2 inhibitors is partly due to the anxiety voiced by primary care doctors about prescribing these medications without consulting a specialist (Sangha et al., 2021; Chonko et al., 2023; Forbes et al., 2024). 5-3 Institutional Guidelines Hospital and clinic rules, such as prescription guidelines and formulary limits, also influence the use of SGLT2 inhibitors. Certain facilities only prescribe these medications through specialists, restricting general practitioners' use. Some institutions do not include SGLT2 inhibitors in their routine treatment procedures, further inhibiting their use (Overview | Type 2 diabetes in adults: management | Guidance | NICE, 2015; Madaan, Akhtar and Najmi, 2016; Newman, 2020; Khunti et al., 2022). 5-4 Assistance for the Healthcare System The quality of assistance provided by the healthcare system, including resources for patient education and access to specialised consultation, can influence clinicians' prescription practices (Korayem et al., 2022; Campbell et al., 2023). 6. Impact of Clinical Guidelines and Evidence Variations and contradictions in clinical guidelines, analysis of medical records, and conflicting directives influence physicians' prescription practices. The quality of healthcare system support the availability of resources for patient education and specialised consultation also play a substantial role in physicians' decision-making. Decisions on interpreting published research findings can differ, with more emphasis on benefits or risks. Also, clinical trial results can contradict themselves. This disparity results in variability in prescription procedures (Anker et al., 2021; Young et al., 2023; Forbes et al., 2024). 6.1 Analysis of Medical Records Physicians’ understanding of clinical trial findings also influences their prescription practices. Decisions about prescriptions may alter depending on whether emphasis on benefits or risks (Hinton et al., 2021; Korayem et al., 2022; Forbes et al., 2024 ; Campbell et al., 2023). 6.2 Confronting Directives Contradictions in clinical guidelines addressing the use of SGLT2 inhibitors have exacerbated physician reluctance and uncertainty. This disparity results in variability in prescription procedures (Jeong et al., 2021; Korayem et al., 2022). Table -1 Factors Influencing Prescription of SGLT2 Inhibitors: nary tract infections (UTIs) and genital infections betic Ketoacidosis (DKA) tors te kidney injury (AKI) uencing ume Depletion and Hypotension scription putation ncerns about side effects LT2 SGLT2-i k of Bone Fractures ibitors oes not know much about SGLT2 inhibitors and is ufficiently familiar with them. king of confidence regarding extended certainty regarding policies results training stricted knowledge and ps in education erience  ited or lack of education and training comorbidities and age herence to dication compliance tors related to patients ent preferences and health literacy ancial aspects g prices astructure for Healthcare ert assistance itutional guidelines temic obstacles in lthcare istance for the healthcare system ntradictory guidelines alysis of medical records nfronting directives ical guidelines and dence impact alysis of clinical data Factors influencing physicians’ reluctance to prescribe SGLT2 inhibitors and identification of primary barriers to prescribing SGLT2 inhibitors; concerns about adverse effects, medical knowledge deficits, patient’s characteristics, economic considerations, systematic barriers in the healthcare system, clinical guidelines. Table - 2 The factors Influencing Prescription of SGLT2 Inhibitors: Impact on Prescription Decision:. Lack of updated Training Factors Influencing Prescription of SGLT2 Inhibitors mpact on Prescription Decision hysicians’ knowledge factor atterns lack a review of the ollow existing protocols alance between risk and enefits rofessional responsibilities to Working within system limitations to make changes and dapt to new approaches maintain. Patient Characteristics Influencing Physicians' Decision to Prescribe SGLT2 nhibitors  atient Factor mpact on Prescription Decision ge lderly patients are less likely to be prescribed Comorbidities ncreased risk leads to hesitancy atient Preferences on-compliance concerns lead to alternative treatments ealth Literacy ow literacy associated with reduced prescriptions. Economic and Systemic Factors Influencing Prescription of SGLT2 Inhibitors conomic/Systemic Factor mpact on Prescription Decision Cost of Medication igh cost reduces prescription rates ealthcare System Support ack of support leads to hesitancy. Influence of Clinical Guidelines on Prescription Decisions Guideline Influence mpact on Prescription Decision ncreases the likelihood of prescription trong Endorsement of Benefits mphasis on Risks ecreases the likelihood of prescription Conflicting Guidelines his leads to variability in decisions Physicians' lack of experience and confidence in prescribing SGLT2 inhibitors contributes to reluctance. - Uncertainty about long-term results and lack of knowledge about SGLT2 inhibitors among general practitioners are key factors. - Rapid changes in therapeutic recommendations and gaps in education also contribute to uncertainty regarding policies and prescribing practices. Patient factors such as age, comorbidities, and medication adherence influence doctors' decisions when prescribing SGLT2 inhibitors. A flow diagram illustrate the study selection process (PRISMA-P Group et al., 2015). SOURCES SPREADSHEET: In the context of the research question, a comprehensive report summarised the findings, results, implications, limitations, gaps, challenges, recommendations and conclusions based on synthesising evidence related to the factors contributing to hesitancy in initiating SGLT2 inhibitors from physicians' perspectives. The study's results informed the results, discussions, limitations, gaps and conclusions. SOURCES SPREADSHEET: https://docs.google.com/spreadsheets/d/1oG6meSwjFS3iJfRVasLFz7hOJtNLKaN6/edit?gid =183416899#gid=183416899 Discussion: This systematic review identifies several reasons physicians are reluctant to recommend SGLT2 inhibitors for treating type 2 diabetes. The main obstacles include potential adverse effects, medical knowledge gaps, patient-specific issues, systemic and economic influences, clinical guidelines and therapeutic recommendations. This systematic study highlights the complexity of these obstacles. Physicians' concerns about SGLT2-i side effects, UTIs, genital infections, and DKA present a significant barrier to the broader use of these drugs. Physicians' concerns can be addressed through educational programs to enhance their expertise and confidence in managing these risks. Clinicians need sufficient knowledge to reduce hesitancy, particularly in primary care settings. Continuous medical education and updated clinical guidelines clearly define their role in managing type 2 diabetes, which can improve their knowledge and confidence while recommending SGLT2 inhibitors (Jeong et al., 2021; Forbes et al., 2024). Patient-related characteristics, such as adherence, age, and comorbidities, influence prescription decisions. Customising SGLT2 inhibitor prescriptions to each patient's unique needs and offering adherence assistance can improve patients' uptake of these medications (Khunti et al., 2022; Korayem et al., 2022; Forbes et al., 2024). Policy changes that improve their cost and insurance coverage may facilitate the broader utilisation of these drugs. Overcoming healthcare hurdles, such as poor infrastructure and limited access to experts, is crucial to maximising the use of SGLT2 inhibitors (Glover et al., 2022; Campbell et al., 2023). A multimodal intervention must address physicians' hesitancy in prescribing SGLT2 inhibitors. Ongoing medical education, training courses, and conversations with healthcare practitioners can help customise treatments to target specific adoption obstacles (Campbell et al., 2023; Chonko et al., 2023). Improved training and education can boost physicians' confidence in prescribing SGLT2 inhibitors. Initiatives such as webinars, workshops, and distribution of clinical guidelines are essential in addressing physician reluctance (Jeong et al., 2021; Korayem et al., 2022). Ongoing research evaluates the long-term efficacy and safety of SGLT2 inhibitors, considering the wide disparity among patients requiring long-term therapy. This led to continuous rapid changes in therapeutic recommendations around the use of SGLT2-i, resulting in uncertainty. Notably, there is a need for more extensive CME programs focused on SGLT2 inhibitors to enhance physicians' proficiency in prescribing and managing these medications' adverse effects (Overview | Type 2 diabetes in adults: management | Guidance | NICE, 2015; Neal et al., 2017; Newman, 2020; Hinton et al., 2021; Korayem et al., 2022). Strategies can be employed to overcome these obstacles, including strengthened education and training, patient-centred methods, and simplification of clinical guidelines. However, it is essential to acknowledge the limitations of this evaluation, including the variability of included papers, research designs, and potential publication bias, which may have impacted the results. Changes in clinical recommendations and evidence over time have also influenced the findings (Campbell et al., 2023; Chonko et al., 2023; Neuen et al., 2024). Table – 3 A. Factors of the reluctance of physicians to prescribe SGLT2 inhibitors B. Identification of primary barriers to prescribing SGLT2 inhibitors A. Factors of the reluctance of B. Identification of primary barriers to physicians to prescribe SGLT2 prescribing SGLT2 inhibitors inhibitors I. Factors influencing physicians' A. Concerns about adverse effects hesitation B. Medical knowledge deficits C. Patient characteristics D. Economic considerations E. Systematic Barriers in the Healthcare System F. Clinical Guidelines II. Complexity of factors influencing A. Emphasis on the multifaceted nature of SGLT2 inhibitor recommendation the barriers B. Legitimate concerns regarding potential side effects C. Need for targeted educational initiatives to alleviate apprehensions III. Addressing physician hesitancy A. Importance of continuous medical education and updated clinical guidelines B. Need for more experience, particularly in primary care environments C. Influence of patient-specific factors on prescription practices IV. Strategies to overcome challenges A. Policy reforms to improve cost B. Addressing healthcare barriers such as inadequate infrastructure and limited access to specialists C. Importance of tailored strategies for surmounting challenges V. A comprehensive approach to A. Vital component of ongoing medical addressing physicians' hesitancy education and training B. Engaging healthcare providers in discussions about their concerns C. C. Enhancing training and education to bolster physicians' confidence VI. Importance of educational A. Policy reforms to improve cost initiatives B. Addressing healthcare barriers such as inadequate infrastructure and limited access to specialists A. C. Importance of tailored strategies for surmounting challenges VII. Funding for education and A. Impact on care standards for type 2 training diabetes patients B. Strengthened education to enhance physicians' confidence in prescribing SGLT2 inhibitors VIII. Patient-centred methods A. Involving patients in decision-making B. Enhancing health literacy and addressing individual concerns C. Importance of shared decision-making and tailored interventions IX. Simplifying clinical guidelines A. Reducing ambiguity in prescribing practices B. Defining clear clinical criteria for SGLT2 inhibitors C. Mitigating confusion through concise, evidence-based guidelines X. Evaluation's limitations A. Variability in the included studies B. Diverse research designs  C. Potential publication bias Limitations: The variability of the included papers, the range of research designs, and the possibility of publication bias all limit this evaluation. How clinical recommendations and evidence change over time might also impact the results. Safety apprehensions surrounding SGLT-2 inhibitors affect prescription practices. Healthcare providers need to clarify discrepancies in clinical guidelines. Primary care practitioners exhibit a deficit in education concerning SGLT-2 inhibitors. Limited comprehension of socioeconomic determinants is influences SGLT2i utilisation. The low rate of SGLT-2 inhibitor prescribing necessitates further investigation. Dependence on precise documentation within medical records is essential (Hinton et al., 2021; Jeong et al., 2021; Sangha et al., 2021; Khunti et al., 2022; Korayem et al., 2022; Forbes et al., 2024; Neuen et al., 2024). GAP: The study reveals a clinical practice gap in SGLT2 inhibitor prescribing trends in T2DM patients, highlighting the need for precise documentation, improved consistency in guidelines, enhanced education, and exploration of socioeconomic factors affecting uptake (Hinton et al., 2021; Jeong et al., 2021; Sangha et al., 2021; Khunti et al., 2022; Korayem et al., 2022; Forbes et al., 2024; Neuen et al., 2024). It also calls for further research on long-term safety outcomes, data on SGLT-2 inhibitor effects in underrepresented groups, and an understanding of physician-related barriers. Adherence rates can vary between clinical trials and actual clinical practice, and the underutilisation of SGLT-2 inhibitors is an ongoing research topic (Hinton et al., 2021; Jeong et al., 2021; Sangha et al., 2021; Khunti et al., 2022; Korayem et al., 2022; Forbes et al., 2024; Neuen et al., 2024). Conclusions: Understanding the multifaceted reasons behind physician reluctance to prescribe SGLT2 inhibitors is essential for optimising their utilisation in clinical practice. Addressing these concerns through targeted educational initiatives, policy reforms, and systemic actions can enhance the adoption of SGLT2 inhibitors and improve patient outcomes. Summary of Key Points and Future Implications In conclusion, several variables contribute to physicians' reluctance to prescribe SGLT2 inhibitors for the treatment of type 2 diabetes. The general use of these medications in clinical practice is hampered by a lack of knowledge about their methods of action, possible adverse effects, and long-term results. Healthcare professionals' reluctance to suggest SGLT2 inhibitors is partly due to worries about the elevated risk of genitourinary infections, euglycemic ketoacidosis, and cardiovascular complications. Serious adverse events related to SGLT-2i are rare, and most potential risks are effectively managed through physician education and awareness. In real-world evidence-based decision-making in diabetes treatment, future research should concentrate on determining the safety and effectiveness of these medications in various patient groups, keeping the audience engaged and interested in the topic. Increasing knowledge of the cardiovascular and renal benefits of SGLT-2is will facilitate their integration into clinical practice for a broader range of patients. Physician confidence in using SGLT2 inhibitors as part of a comprehensive treatment strategy for patients with type 2 diabetes may increase by addressing these knowledge gaps through targeted education and continuing medical education programs. Ongoing real-world evidence will further inform the safety and efficacy of SGLT-2is, particularly in underrepresented populations, enhancing treatment optimisation. Finally, the key issues about physicians' reluctance to prescribe SGLT2 inhibitors for treating type 2 diabetes have been addressed by examining the literature. The leading causes of physicians' hesitation are their need for familiarity with the medicine, worries about potential adverse effects, and ambiguity regarding the treatment's long-term impact on patient outcomes. To increase their confidence in prescribing SGLT2 inhibitors, healthcare professionals must continue their education and training on the advantages and disadvantages of these drugs. Future studies should also clarify these medications' long-term safety and effectiveness and devise plans to alleviate physician worries and obstacles to adopting these medications. The healthcare system may enhance patient outcomes and facilitate the efficient treatment of type 2 diabetes by tackling these crucial topics and their implications. Prospective investigations clarify these medications' enduring effectiveness and safety, together with devising approaches to tackle physician apprehensions and adoption impediments. The healthcare system may better support the efficient treatment of type 2 diabetes and enhance patient outcomes by addressing these critical issues and their consequences. The findings indicate that addressing the knowledge gaps, uncertainties, and patient-related factors is crucial in reducing physicians' hesitancy in prescribing SGLT2 inhibitors for managing T2DM. Further research and targeted educational initiatives are warranted to improve physicians' confidence and competence in utilising these medications effectively. This progress report provides an overview of the factors influencing physicians' hesitancy to prescribe SGLT2 inhibitors and sets the stage for further investigation into addressing these barriers. The ongoing research project has provided valuable insights into the factors contributing to physicians' reluctance to prescribe SGLT2 inhibitors for managing T2DM. The identified factors will inform the development of strategies to mitigate these challenges and enhance the clinical adoption of SGLT2 inhibitors, ultimately improving patient outcomes. An overview of the main ideas and their future implications: A. Addressing issues through targeted educational campaigns and systemic actions B. Promotion of SGLT2 inhibitor uptake and improved clinical outcomes C. The need for future research on the safety and effectiveness of SGLT2 inhibitors