Contemporary National Patterns of Eligibility and Use of Novel Cardioprotective Antihyperglycemic Agents in Type 2 Diabetes Mellitus

Abstract

Background Sodium glucose transporter‐2 (SGLT‐2) inhibitors and glucagon‐like peptide‐1 receptor agonists (GLP‐1RAs) effectively lowered cardiovascular risk in large clinical trials for patients with type 2 diabetes at high risk for these complications, and have recommended by guidelines. To evaluate the contemporary landscape in which these recommendations would be implemented, we examined the use of these medications according to clinical guideline practice. Methods and Results In the National Health and Nutrition Examination Survey for 2017‐2018, we defined compelling indications for SGLT‐2 inhibitors by the presence of atherosclerotic cardiovascular disease (ASCVD), heart failure, or chronic kidney disease (CKD), and for GLP‐1RAs by the presence of established or high risk ASCVD, based on large clinical trials that have been incorporated in guideline recommendations of the American College of Cardiology (ACC) and American Diabetes Association (ADA). We then evaluated utilization of these medications among patients with physician‐diagnosed type 2 diabetes. All analyses incorporated complex survey design to produce nationally representative estimates. A total 1104 of 9254 sampled individuals had type 2 diabetes, representing 10.6% (95% CI 9.7‐11.6) of the US population or 33.2 million adults nationally. Of these, 52.6% (47.7‐57.5) had an indication for SGLT‐2 inhibitors, 32.8% (28.8‐37.2) for GLP‐1RAs, and 26.6% (22.2‐31.7) for both medications. During 2017‐2018, 4.5% (2.4‐8.2) were treated with SGLT‐2 inhibitors and 1.5% (0.7‐3.2) with GLP‐1RAs. ASCVD, heart failure, or CKD were not independently associated with SGLT‐2 inhibitor or GLP‐1RA use in patients with diabetes. Conclusions Despite a large number of patients being eligible for guideline recommended cardiorenal protective therapies, there are substantial gaps in the use of SGLT‐2 inhibitors and GLP‐1RAs, limiting their public health benefits.

Patterns of Medication Use and Prescription Fills for Cardioprotective Anti-Hyperglycemic Agents in the United States

“…The present results support the observations of prior studies suggesting low rates of prescriptions of these medications, [9][10][11] with this study reporting the latest data on the real-world use of GLP-1 RAs and SGLT-2i in a large and diverse population across the US. The constellation of these findings suggests a guideline-discordant prescription pattern that does not adequately incorporate trial-proven non-glycemic benefits of these two drug classes.…”

“…6 Despite the expanding indications for GLP-1 RAs and SGLT-2i in clinical guidelines and society recommendations for cardiovascular and kidney benefits, the overall prescriptions of these medications remain low. [9][10][11][12] Furthermore, the clinical benefits of GLP-1 RAs and SGLT-2i are only achieved if patients continually take these medications after prescription, underscoring the importance of both prescription and consistent use. In the absence of high-quality data on the evolving use of GLP-1 RAs and SGLT-2i in the real world, assessment of their consistent use after initiation of therapy has been challenging.…”

County-level variation in cardioprotective antihyperglycemic prescribing among medicare beneficiaries

“…In nationally representative data assessments, 65% and 40% of patients with type 2 diabetes age 65 years or older have indications for SGLT2i and GLP-1RA, respectively [ 7 ]. However, there has been limited adoption of these drugs in real-world practice, with less than 10% of eligible patients receiving these therapies [ 7 – 10 ]. It is unknown if geographic variation exists in the prescribing of cardioprotective antihyperglycemic drugs.…”

Specialty Visits and Real-world Initiation of Cardioprotective Anti-hyperglycemic Medications Among US Adults with Type 2 Diabetes

“…Fewer than 1 in 10 patients with guideline-directed class I indications receive these medications in the US. 1 With substantial prescriber-level variation for SGLT-2i and GLP-1RA prescriptions, 2 the impact of healthcare visits with specific specialty providers on the use of these medications has not been well characterized. In a prospective nationwide cohort of US adults with compelling indications for SGLT-2i and GLP-1RA use followed for 2 years, we evaluated whether care received from certain clinical specialists portended successful initiation of these essential drugs.…”