Importance: Selected glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium glucose cotransporter-2 inhibitors (SGLT2i) have cardioprotective effects in patients with type 2 diabetes and elevated cardiovascular risk. Prescription of these agents by clinicians and their consistent use by patients are essential to realize their benefits. Objective: To assess the patterns of use and prescription fills of GLP-1RAs and SGLT-2i. Design: Cross-sectional for medication use and prospective for prescription fills in 2018-2020 Setting: Nationwide de-identified US administrative claims database of Medicare Advantage and commercially insured adults. Participants: Individuals 18 years of age and older with type 2 diabetes Exposures: Comorbidities representing guideline-directed indications of atherosclerotic cardiovascular disease (ASCVD) for GLP-1RAs, and ASCVD, heart failure, and diabetic nephropathy for SGLT2i. Main Outcomes and Measures: Medication use and monthly fill rates for 12 months following initiation of therapy by calculating the proportion of days with consistent medication use. Results: Among 587,657 individuals with type 2 diabetes, 80,196 (13.6%) were prescribed GLP-1RAs and 68,149 (11.5%) SGLT2i during 2018-2020. This represented 12.9% and 10.5% of individuals with indications for each medication, respectively. Based on monthly counts of new prescriptions, there were no changes in the uptake of either drug class during 2019-2020. Among new initiators, fill rate was 52.5% for GLP-1RAs and 52.9% for SGLT2i one year after initiation. One-year fill rates were higher for patients with commercial insurance than those with Medicare Advantage plans for both GLP-1RAs (59.3% vs 51.0%, p-value<0.001) and SGLT2i (63.4% vs 50.3%, p-value<0.001). After adjusting for comorbidity profile, there were higher prescription fills for patients with commercial insurance (versus Medicare Advantage, OR 1.17, 95% CI [1.06-1.29] for GLP-1RAs, and 1.59 [1.42-1.77] for SGLT2i); and higher income (top quartile versus others, OR 1.09 [1.06-1.12] for GLP-1RAs, and 1.06 [1.03-1.10] for SGLT2i). Conclusions and Relevance: In 2018-2020, use of GLP-1RAs and SGLT2i remained limited to fewer than 1 in 8 individuals with type 2 diabetes meeting criteria for evidence-based guideline and professional society recommendations, with one-year fill rates around 50%. The low and inconsistent use of these medications compromises their longitudinal health outcomes benefits in a period of expanding indications for their use.
Background: Sodium glucose cotransporter-2 inhibitors (SGLT-2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) are the only cardioprotective anti-hyperglycemic medications, but have had limited use. We evaluated whether access to specialty cardiovascular care improves the uptake of these cardioprotective medications in type 2 diabetes (T2D). Methods: In a retrospective cohort study between Jan 2019 and Dec 2020, beneficiaries with Medicare Advantage or commercial insurance were followed using Optum Labs’ de-identified administrative claims for the initiation of SGLT-2i and GLP-1RA among eligible adults with T2D across specialty visits. Eligibility included atherosclerotic cardiovascular disease (ASCVD), heart failure, or diabetic nephropathy for SGLT-2i and ASCVD for GLP-1RA. Detailed demographic and comorbidity information was obtained from the year before cohort enrollment. Results: Among eligible individuals for SGLT-2i (N=294,988) and GLP-1RA (N=198,525), 10.4% and 16.7% initiated these medications during the study period, respectively. Overall, 57% of those with an indication for SGLT-2i and 64% for GLP-1RA had at least one visit with a cardiologist. After accounting for differences in clinical characteristics and comorbidities, those with a visit with a cardiologist had higher odds of initiating SGLT-2i (OR = 1.26 [1.21-1.30]) and GLP-1RA (OR=1.05 [1.01-1.10]). However, these were not higher than those receiving care from family medicine and internal medicine providers and were substantially lower than those receiving care from an endocrinologist (Figure). Conclusion: In 2019-2020, among insured individuals with compelling CV indications, despite broad access to cardiovascular care, receiving care from cardiologists was only modestly associated with uptake of novel therapies. Efforts to improve the use of these medications are less likely to benefit from efforts to broaden access to specialty cardiovascular care.
Prescription of sodium glucose cotransporter-2 inhibitors (SGLT-2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) among patients with guideline-directed indications remains limited with substantial inter-prescriber variability. In this prospective study of US adults, we used administrative claims database of individuals with type 2 diabetes and compelling indications for SGLT-2i and GLP-1RA to evaluate the impact of healthcare visits with certain specialty providers on the initiation of these medications. These specialties included family medicine, internal medicine, cardiology, endocrinology, and nephrology. Overall, 294,988 individuals eligible for SGLT-2i and 198,525 for GLP-1RA were identified. In 2019-2020, SGLT-2i and GLP-1RA were initiated in 10.4% and 16.7% of eligible individuals, respectively. After accounting for patient characteristics and comorbidities, healthcare visit with endocrinologists was associated with the highest rate of initiation of either drug across specialties (OR=2.16 [2.08-2.24] for SGLT-2i, and 2.76 [2.64-2.88] for GLP-1RA). Healthcare visits with cardiologists and with family medicine and internal medicine physicians were only modestly associated with initiation of SGLT-2i and GLP-1RA. The study highlights the need for broad education for expansion of the use of these medications rather than focus on dedicated specialty clinics.
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