Twelve‐year trends in pharmacologic treatment of type 2 diabetes among patients with heart failure in the United States

Abstract

We conducted a cross‐sectional analysis using a database from commercial health plans in the United States to describe trends in the use of antidiabetic medications among patients with type 2 diabetes and heart failure (HF) from 2006 through 2017. We used loop diuretic dose as a surrogate for HF severity (mild HF 0‐40 mg/day, moderate‐severe HF >40 mg/day). We assessed antidiabetic medication dispensing in the 90 days following HF diagnosis. Over the 12‐year period, we identified an increase in the use of metformin (39.2% vs. 62.6%), dipeptidyl peptidase‐4 inhibitors (DPP‐4i) (0.5% vs. 17.1%) and sodium‐glucose co‐transporter‐2 inhibitors (SGLT‐2i) (0.0% vs. 9.0%), but a decrease in the use of sulphonylureas (47.8% vs. 27.8%) and thiazolidinediones (TZDs) (31.7% vs. 5.3%). In 2017, patients with moderate‐severe HF more commonly used insulin (43.1%); a majority of mild HF patients used metformin (62.8%). A proportion of patients with moderate‐severe HF used TZDs (4.4%). Among patients with diabetes and HF, the use of metformin and DPP‐4i rapidly increased, but a proportion of patients with moderate‐severe HF continued to use TZDs. Despite their promising cardiovascular safety profile, SGLT‐2i use remains limited.

Changes in Type 2 Diabetes Medication Utilization and Costs in the United States, 2014–2019

“…2 Likewise, sulfonylureas have been increasingly questioned for patients at risk for hypoglycemia such as the elderly and those with preexisting heart disease. [6][7][8] While prior studies have described trends in antidiabetic medication utilization and costs over time, [9][10][11][12] none have included data as recently as 2019, nor have they comprehensively examined changes in a national dataset across types of insurance plans (Medicare, Medicaid, and commercially insured).…”

Compared to commercially insured patients, Medicare advantage patients adopt newer diabetes drugs more slowly and adhere to them less

“…5 Concerns about contraindications, safety, tolerability and cost all have the potential to hasten or slow the adoption of newer diabetes drugs in specific populations. 3 For example, since the newer diabetes drugs have no generic equivalents and remain relatively expensive, professional guidelines note that older drug classes such as sulphonylureas and thiazolidinediones may be preferred in those patients with limited financial means, since substantial empirical evidence supports that high cost may translate into poor adherence. 1,[6][7][8][9][10] At the same time, the increased risk of hypoglycaemia in older adults has led some providers to recommend adopting newer drugs more quickly in that population.…”

“…New drugs for treatment of type 2 diabetes mellitus (T2DM) have proliferated over the past 15 years, with the introduction of glucagon-like peptide 1 (GLP-1) receptor agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors and sodium-glucose transport protein 2 (SGLT-2 inhibitors). [1][2][3][4] These agents were originally promoted for having fewer risks of hypoglycaemia and weight gain than older diabetes drugs. The newer diabetes drug classes have also benefited from large recent clinical trials showing that SGLT-2 inhibitors and GLP-1 receptor agonists prevent major adverse cardiovascular events and progression of kidney disease.…”

“…New drugs for treatment of type 2 diabetes mellitus (T2DM) have proliferated over the past 15 years, with the introduction of glucagon‐like peptide 1 (GLP‐1) receptor agonists, dipeptidyl peptidase‐4 (DPP‐4) inhibitors and sodium‐glucose transport protein 2 (SGLT‐2 inhibitors) 1‐4 . These agents were originally promoted for having fewer risks of hypoglycaemia and weight gain than older diabetes drugs.…”

“…While adoption of newer diabetes drugs has been significant, sulphonylureas remain the most commonly used second‐line agent overall 5 . Concerns about contraindications, safety, tolerability and cost all have the potential to hasten or slow the adoption of newer diabetes drugs in specific populations 3 . For example, since the newer diabetes drugs have no generic equivalents and remain relatively expensive, professional guidelines note that older drug classes such as sulphonylureas and thiazolidinediones may be preferred in those patients with limited financial means, since substantial empirical evidence supports that high cost may translate into poor adherence 1,6‐10 .…”