Newer Diabetes Drugs Still Under-Prescribed in High-Risk Patients

NEW ORLEANS — Patients at a community health center who had type 2 diabetes and a high risk of atherosclerotic cardiovascular disease (ASCVD) were under-prescribed guideline-recommended treatment with sodium-glucose cotransporter-2 (SGLT-2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists, a single-center study found.

Of patients who met the high-risk criteria, 55% were not on American Diabetes Association (ADA) guideline-directed medication therapy with an SGLT-2 inhibitor or GLP-1 agonist. In only 34% of these cases was there an appropriate documented reason given, said Holly C. Johnson, PharmD, of Atrium Health Navicent in Macon, Georgia, who presented the findings at the American Society of Health-System Pharmacists midyear meeting here.

The ADA has recommended use of SGLT-2 inhibitors as first-line drugs for patients with diabetes and cardiovascular disease since 2019, after several trials demonstrated substantial benefit for SGLT-2 inhibitors in these patients. Other major societies have also updated their guidelines to recommend use of SGLT-2 inhibitors for these patients. Johnson added that GLP-1 agonists can also be used as they’ve shown heart benefits as well.

However, uptake of these medications has been slow, and according to previous studies, sulfonylureas and dipeptidyl peptidase-4 inhibitors continue to be more commonly prescribed. SGLT-2 inhibitors include empagliflozin (Jardiance) and dapagliflozin (Farxiga), and GLP-1 agonists include semaglutide (Ozempic) and liraglutide (Victoza).

Johnson said WT Anderson Community Health Center Resident Medicine Clinic in Macon, where the study was conducted, treats a “very underserved,” and “very poorly insured” population who were mostly taking metformin to control diabetes. The clinic offers a patient assistance program for certain drugs; research has found that both SGLT2 inhibitors and GLP-1 agonists cost much more than metformin over a patient’s lifetime. Poor uptake of these drugs is consistent with other research that has found disparities in the prescribing of these agents to adults with diabetes and cardiovascular disease by race, ethnicity, and income.

“The use of these evidence-based medications remains low. We need to work on both therapeutic inertia … as well as other contextual barriers which are important (for example, financial barriers and lack of coverage),” Salim S. Virani, MD, PhD, of Aga Khan University in Karachi, Pakistan, who was not involved in the study but has researched utilization rates of SGLT-2 inhibitors, told MedPage Today in an email.

“Multipronged efforts need to be directed towards clinicians, patients, and the healthcare system to ensure that clinicians can prescribe the medications easily, that they actually prescribe the medications after discussing this with the patients, and that patients take the medications as prescribed,” Virani added.

Johnson and colleagues included patients age 18 or older seen at WT Anderson from January through March 2024. All had a diagnosis of type 2 diabetes and either a history of ASCVD or at least two additional risk factors such as end-organ damage, hypertension, smoking, or dyslipidemia.

Patients with a previously documented reason for not taking a GLP-1 agonist or SGLT-2 inhibitor were excluded, as were those visiting for a blood pressure check, nurse visit, or injection/vaccine. Only one visit from each patient was included in the study period.

In all, 180 patients were classified as high-risk. Of the 99 patients who were not on either a GLP-1 agonist or an SGLT-2 inhibitor, approximately one-third had a documented reason. For SGLT-2 inhibitors, the most common reasons given were having an A1C ≥ 9% (42%), intolerance to the agent (19%), and financial constraints (16%). For GLP-1 agonists, the top reason given was financial constraints (55%), followed by patient preference and intolerance (18% each).

Notably, Johnson found that nearly half the patients with no documented or presumed reason for not having an SGLT-2 prescription had a controlled hemoglobin A1c

“For SGLT-2s, I did not realize I was going to find if they’re controlled, they’re not starting it. So now that’s my thing,” Johnson added. “I’m going to make sure there is more education out there. So if your A1c is controlled, you still need to be on one of these agents.”

Study limitations included that the research was conducted at a single center and thus may not be generalizable to other healthcare facilities or populations, and that the researchers did not collect demographic information about the patients.

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