Inadequate Use of Newer Treatments and Glycemic Control by Cardiovascular Risk and Sociodemographic Groups in US Adults with Diabetes in the NIH Precision Medicine Initiative All of Us Research Program

Abstract

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.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

“…Recent data from the All of Us Research Program (2018–2022) show that 73% of US adults with diabetes have an HbA1c <7%, with control slightly better in women (73.6%) than in men (69.8%) and in NH White individuals (78.3) and Asian individuals (76.3%) compared with NH Black (65.1%) or Hispanic/Latino (60.8%) individuals. 101 Overall, 50.6% of the participants had LDL-C levels <100 mg/dL, although only 16.0% had levels <70 mg/dL, and among those with diabetes and ASCVD, only 21.1% had LDL-C <70 mg/dL. Overall, 64.4% had triglyceride levels <150 mg/dL, and 31.6% had levels <100 mg/dL.…”

“…In the US Precision Medicine Initiative All of Us Research Program including >80 000 patients with diabetes studied during 2018 to 2022, among those with both diabetes and ASCVD, only 8.6% were on an SGLT-2 inhibitor and 11.9% were on a GLP1-RA, with <10% of those with HF or CKD on an SGLT-2 inhibitor. 101 Moreover, only 18.2% were on high-intensity statins, and use of ezetimibe and PCSK9 inhibitors was also low (5.1% and 0.6%, respectively). Among those with triglycerides >150 mg/dL, only 1.9% were taking icosapent ethyl.…”

Prescribing Patterns of SGLT2 inhibitors and GLP-1 receptor agonists in Patients with T2DM and ASCVD in South Korea

“…Given that weight loss is more pronounced in women than men [36,37], it is plausible that GLP1RA were prescribed more frequently for weight management in women and were their preferred choice [38]. There was no signi cant trend to use more SGLT2i for female patients, in contrast to the ndings from previous studies [21,25,39].…”

“…For those intolerant to dual oral agents, additional criteria such as BMI ≥ or contraindication to insulin were required. The extremely low utilization of GLP1RA compared with that in other countries [19,[23][24][25] could be explained by these strict insurance cover requirements. Government efforts to lower the insurance cover threshold for SGLT2i and GLP1RA are needed to ensure adequate utilization of these agents.…”

“…Despite these updated guidelines, global data have indicated insu cient utilization of SGLT2i and GLP1RA [18][19][20][21][22][23][24][25]. A nationwide study in the United States showed that the utilization rate of SGLT2i and GLP1RA increased between 2018 and 2021 in patients with T2DM and ASCVD; however, these agents remained underused in comparison with other antidiabetic agents, such as sulfonylureas (SU) and dipeptidyl-peptidase 4 inhibitors (DPP4i) [19].…”