1247-P: Anticipating the Impact of 2019 Guidelines: Use of SGLT2i and GLP-1RA in Patients with Diabetes and Cardiovascular Disease

Abstract

Objective: To describe use of GLP-1 RA and SGLT2i in the treatment of patients with diabetes and cardiovascular disease (CVD) using a large, clinical database. Study Design: A retrospective descriptive analysis in a clinical database with 22 million longitudinal patient records across 22 health care organizations (HCOs). Population Studied: A total of 2.6 million patients aged 18-75 with ≥ 2 ambulatory visits with primary care, endocrinology, cardiology, or nephrology in the past 18 months were included from 1/2013 to 3/2018. A subset of 350,000 patients with a type 2 diabetes (DM) diagnosis was observed during the 36 months ending 2016 Q1, 2017 Q1, 2018 Q1 for existing or new prescriptions of novel antidiabetic agents: GLP-1, SGLT2, or DPP-4. Patients were stratified by presence of cardiovascular disease (CVD), baseline DM medication regimen, and HbA1c ≥ 8.0, indicating need for advancing therapy. Principal Findings: In 2018 Q1, the prevalence of CVD among patients with type 2 DM was 31%. Among patients with type 2 DM, a baseline oral antidiabetic regimen, and HbA1c ≥ 8.0, those with CVD were more likely to have any new DM medication class added (51% vs. 44%, p < 0.001), but no more likely than those without CVD to have a GLP-1 or SGLT2 added (p = 0.70). Patients with CVD were more likely to be prescribed insulin than those without evidence of CVD (20.2% vs. 10.3%, p < 0.001). From the 3-year period ending 2016 Q1 to that ending 2018 Q1, GLP-1 and SGLT2 prescriptions increased 3% and 4%, respectively, among all patients with type 2 DM. Conclusions: Overall prescriptions of GLP-1 and SGLT2 are increasing but represent only 12% and 13%, respectively, of prescriptions for patients with type 2 DM (vs. 20% for DPP-4). Among patients with type 2 DM, these agents were prescribed no more frequently to those with established CVD than to those without CVD. Prescribing behavior complied with the new guidelines in only 14% of patients with both type 2 diabetes and CVD (range 8-31% across 20 HCOs). Disclosure C.R. Rattelman: None. E.L. Ciemins: None. J.K. Cuddeback: None. Funding Novo Nordisk

Worldwide inertia to the use of cardiorenal protective glucose-lowering drugs (SGLT2i and GLP-1 RA) in high-risk patients with type 2 diabetes

“…The evidence from CVOTs-and supporting, confirmatory data from real-world evidence studies-has led guidelines to advocate increasing the use of SGLT2i and GLP-1 RA [35,36,[49][50][51] and, from the authors' perspective, profoundly changed our clinical practice. However, prescribing evidence from North America and Europe suggests that most eligible patients are still not receiving these agents [26][27][28][29][30] (Fig. 2), despite their proven cardiorenal benefits and the urgency of addressing CV and renal risk as comorbidities that pose the biggest threat to life in T2D.…”

“…According to recent surveys of prescribing habits, only modest increases in SGLT2i and GLP-1 RA use have been observed during the CVOT era; to compound the issue, prescribing rates for the two classes, as new agents, have historically been low [26][27][28][29]. For example, among several hundred thousand US patients with T2D and established CVD who received glucose-lowering drugs between 2014 and 2018, the proportion taking SGLT2i did increase after the publication of EMPA-REG OUT-COME, but only from 4.1% in 2015 to 7.2% in 2018 [26].…”

“…Consistent with this finding, a 2014-2017 study focusing on cardiology centres found that patients with established ASCVD or at high risk of CV events were around threefold more likely to be taking DPP-4i than SGLT2i or GLP-1 RA [31,37]; while a study focusing on primary care from January 2013 to April 2016 found that 23% of >250,000 US patients with T2D received DPP-4i second-line to metformin, compared with 4% receiving SGLT2i and 6% receiving GLP-1 RA [64]. Even by 2019, patients with T2D and CVD were [26,31]; a rolling 3-year window study of clinical records from 20 US healthcare organisations, with the oldest cohort from Q1 2013 to Q1 2016 and the most recent cohort from Q1 2016 to 2019 [29,30]; a nationwide cohort of new initiators of T2D therapies in Denmark from 2014 and 2017 [28]; and a nationwide registry of medicine utilisation in Denmark from 1996 to 2017, which did not include patient-level data [27]. Contemporary costs of SGLT2i, GLP-1 RA and DPP-4i in 2017, the most recent year captured by all the studies, show that pricing does not seem to explain therapy preferences.…”

“…Data from the US and Denmark show clinical inertia in prescribing SGLT2i or GLP-1 RA, with only modest increases following the disclosures of the first CVOTs to show cardiorenal benefits, in September 2015 (EMPA-REG OUTCOME) and June 2016 (LEADER), respectively. Summaries are shown of data from the US Optum claims database between 2014 and 2018 [ 26 , 31 ]; a rolling 3-year window study of clinical records from 20 US healthcare organisations, with the oldest cohort from Q1 2013 to Q1 2016 and the most recent cohort from Q1 2016 to 2019 [ 29 , 30 ]; a nationwide cohort of new initiators of T2D therapies in Denmark from 2014 and 2017 [ 28 ]; and a nationwide registry of medicine utilisation in Denmark from 1996 to 2017, which did not include patient-level data [ 27 ]. Contemporary costs of SGLT2i, GLP-1 RA and DPP-4i in 2017, the most recent year captured by all the studies, show that pricing does not seem to explain therapy preferences.…”

“…In contrast to SGLT2i and GLP-1 RA, numerous CV outcomes trials (CVOTs) have pointed to a generally neutral effect with dipeptidyl peptidase-4 inhibitors (DPP-4i) [22]. However, despite the high prevalence of cardiorenal risk in patients with T2D [23][24][25], DPP-4i remain more widely used than the similarly priced SGLT2i class in patients with T2D and cardiorenal comorbidities, including CVD, HF and CKD [26][27][28][29][30]. Indeed, the majority of eligible patients still do not receive agents for which protective effects have been proven [26][27][28][29][30], presenting an urgent need to increase uptake of SGLT2i and GLP-1 RA as part of the standard of care for managing cardiorenal risk in patients with T2D [10].…”