GLP-1, SGLT2 initiation rates low among older adults with type 2 diabetes and CVD
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Initiation rates of GLP-1 receptor agonists and SGLT2 inhibitors among older adults with type 2 diabetes and atherosclerotic cardiovascular disease or congestive heart failure remained low from 2016 to 2019, according to study data.
In findings from an analysis of Medicare data published in Diabetes Care, the incidence rate of GLP-1 receptor agonist or SGLT2 inhibitor initiation was 0.34 per 100 person-months from 2016 to 2019, though initiation rates increased each year.
“Although newer diabetes medications are proven to reduce the risk of heart attacks, hospitalization for HF, need for dialysis and even death in people at high risk for these events, the majority of people who would develop a need for these medications are not receiving them,” Sara Cromer, MD, a clinical and research fellow in endocrinology at Massachusetts General Hospital, told Healio. “Additionally, traditionally marginalized groups, including women, Black individuals and those with lower socioeconomic status, are even less likely to receive these medications.”
Cromer and colleagues collected Medicare parts A, B and D claims data from July 2016 to December 2019. Adults aged 65 years and older with type 2 diabetes and incident atherosclerotic CVD or congestive heart failure (HF) and at least 1 year of continuous Medicare enrollment were included. The date of atherosclerotic CVD or HF diagnosis, or the first clinical indication of either condition was defined as the cohort entry date. Adults were considered to have started a GLP-1 receptor agonist or SGLT2 inhibitor if they filled at least one prescription within 180 days of the cohort entry date. Demographics including age, sex, race and ethnicity, region of residence and year of cohort entry were collected. Social deprivation index was calculated at a ZIP code level for each participant.
Older people, Black adults less likely to start medication
There were 4,057,725 adults included in the study (mean age, 75.6 years; 50.8% women; 80% white). The incidence rate for GLP-1 receptor agonist or SGLT2 inhibitor initiation during the study period was 0.34 per 100 person-months. The initiation rate increased from 0.23 per 100 person-months in 2016 to 0.58 per 100 person-months in 2019.
After adjusting for demographics, medical use, comorbidities, health care use measures and social deprivation index, older age was associated with a lower likelihood for prescription initiation (HR = 0.94; 95% CI, 0.94-0.94) and men were more likely to initiation a prescription than women (HR = 1.08; 95% CI, 1.06-1.1). Non-Hispanic Black adults were less likely to initiate a GLP-1 receptor agonist or SGLT2 inhibitor compared with white adults (HR = 0.81; 95% CI, 0.79-0.83). Each 1 standard deviation increase in social deprivation index was associated with a lower likelihood of prescription initiation (HR = 0.96; 95% CI, 0.96-0.97).
“The failure to start these medications in a timely fashion in high-risk populations may result in increased rates of CVD, renal failure and even death,” Cromer said. “The fact that these medications are disproportionately used by men, white individuals and those of higher socioeconomic status will likely broaden already existing disparities in diabetes care.”
Initiation more common for adults with CV risk factors
Adults with CV risk factors were more likely to initiate a GLP-1 receptor agonist or SGLT2 inhibitor prescription, whereas those with markers of end-stage or more severe disease were less likely to start a medication. Adults who previously filled medications for atherosclerotic CVD or HF were more likely to initiate a GLP-1 receptor agonist or SGLT2 inhibitor, whereas the use of other first-line antihypertensive agents was associated with lower rates of GLP-1 receptor agonist or SGLT2 inhibitor use. Other factors associated with a higher rate of GLP-1 receptor agonist or SGLT2 inhibitor initiation included the presence of microvascular complications or use of any other diabetes medication and having a higher number of outpatient encounters with a cardiologist or endocrinologist. Adults with a greater number of ED visits or hospitalizations had a lower rate of medication initiation.
“Our study could not evaluate the impact of these deficits and disparities on rates of clinical events,” Cromer said. “Further studies could better quantify these effects. Implementation studies examining how best to bring general clinical practice in line with expert guidelines would also lead to a better understanding of how to bridge treatment gaps.”
For more information:
Sara Cromer, MD, can be reached at scromer@mgh.harvard.edu.
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