Purpose Data are limited on sodium glucose co-transport 2 inhibitors (SGLT2-is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) among real-world cohorts of underrepresented patients. We examined these therapies and glycemic control in US adults with diabetes mellitus (DM) by atherosclerotic cardiovascular disease (ASCVD) risk and sociodemographic factors. Methods In the NIH Precision Medicine Initiative All of Us Research Program, we categorized DM as (1) moderate risk, (2) high risk, and (3) with ASCVD. We examined proportions on DM therapies, including SGLT2-i or GLP-1 RA, and at glycemic control by sociodemographic factors and CVD risk groups. Results Our 81,332 adults aged ≥ 18 years with DM across 340 US sites included 22.3% non-Hispanic Black, 17.2% Hispanic, and 1.8% Asian participants; 31.1%, 30.3%, and 38.6% were at moderate risk, high risk, or with ASCVD, respectively. Those with DM and ASCVD were most likely on SGLT2-i (8.6%) or GLP-1 RA (11.9%). SGLT2-i use was < 10% in those with heart failure or chronic kidney disease. The odds (95% CI) of SGLT2-i use were greater among men (1.35 [1.20, 1.53]) and Asian persons (2.31 [1.78, 2.96]), with GLP-1 RA being less common (0.78 [0.70, 0.86]) in men. GLP-1 RA use was greater among those with health insurance, and both GLP-1 RA and SGLT2-i greater within lower income groups. 72.0% of participants had HbA1c < 7%; Hispanic persons were least likely at glycemic control. Conclusions Treatment with SGLT2-is and GLP-1 RAs remains low, even among higher ASCVD risk persons with DM and use is even lower among underserved groups.

Real-world data on lipid levels and treatment among adults with diabetes mellitus (DM) are relatively limited. We studied lipid levels and treatment status in patients with DM across cardiovascular disease (CVD) risk groups and sociodemographic factors. In the All of Us Research Program, we categorized DM as (1) moderate risk (≤1 CVD risk factor), (2) high risk (≥2 CVD risk factors), and (3) DM with atherosclerotic CVD (ASCVD). We examined the use of statin and non-statin therapy as well as LDL-C and triglyceride levels. We studied 81,332 participants with DM, which included 22.3% non-Hispanic Black and 17.2% Hispanic. A total of 31.1% had ≤1 DM risk factor, 30.3% had ≥2 DM risk factors, and 38.6% of participants had DM with ASCVD. Only 18.2% of those with DM and ASCVD were on high-intensity statins. Overall, 5.1% were using ezetimibe and 0.6% PCSK9 inhibitors. Among those with DM and ASCVD, only 21.1% had LDL-C < 70 mg/dL. Overall, 1.9% of participants with triglycerides ≥ 150 mg/dL were on icosapent ethyl. Those with DM and ASCVD were more likely to be on high-intensity statins, ezetimibe, and icosapent ethyl. Guideline-recommended use of high-intensity statins and non-statin therapy among our higher risk DM patients is lacking, with LDL-C inadequately controlled.

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Objective: The 2018 Multisociety Cholesterol Guideline categorized patients with atherosclerotic cardiovascular disease (ASCVD) according to very high risk status, but there are few reports of recent medication use and risk factor control by risk group. We examined in a current cohort of US adults the extent of ASCVD risk factor control and treatment by these ASCVD groups. Methods: The NIH Precision Medicine Initiative (All of Us Study) is an ongoing program aiming to enroll > 1 million adults across the US. Since May 2018, >315,000 participants have been recruited from >340 sites nationwide, oversampling underrepresented groups. We studied adults age > 18 years with prior ASCVD, classified based on the 2018 guideline as 1) very high risk with > 2 major ASCVD events, 2) very high risk with 1 major event and > 2 major ASCVD conditions, or 3) ASCVD not at very high risk. We examined proportions at recommended therapies (high intensity statin, blood pressure [BP] and diabetes [DM] medication, and aspirin) and desired levels of risk factors (LDL-C, BP, HbA1c, and non-smoking status) across ASCVD risk categories. Results: Our 34,195 participants with ASCVD included 49% female, 20.5% non-Hispanic Black and 12.9% Hispanic or Latino adults, with an overall age of 66.0 + 12.4 years. 44.6% were classified as very high risk, of which 10.8% had > 2 prior ASCVD evets. The table shows the proportion of each risk group on recommended therapies and risk factor targets. Across ASCVD risk groups use of high intensity statins (10-14%) and attainment of acceptable LDL-C levels (17-27%) and BP levels (42-47%) are markedly suboptimal. Across risk groups only 3-8% were on all 4 recommended therapies and <5% were at all desired levels of all 4 risk factors. Conclusions: Improved efforts are needed to communicate the importance of multiple risk factor control and recommended therapies across the spectrum of ASCVD patients, and especially those at very high risk.