Few hospitalized adults with type 2 diabetes prescribed SGLT2, GLP-1 medication
Key takeaways:
- Among hospitalized adults with type 2 diabetes from 2015 to 2020, 3.7% were prescribed an SGLT2 inhibitor.
- Only 0.2% of hospitalized adults with type 2 diabetes were prescribed a GLP-1 receptor agonist.
Less than 5% of hospitalized adults with type 2 diabetes received an SGLT2 inhibitor or GLP-1 before being discharged, according to data from a cohort study published in the Journal of Diabetes and Its Complications.
“In this multicenter study of over 250,000 hospitalizations, use of novel diabetes medications prior to discharge was rare, raising the concern for systematic underutilization after discharge,” Michael Fralick, PhD, MD, MSc, assistant professor in the department of medicine at University of Toronto and clinical scientist at Sinai Health in Toronto, and colleagues wrote. “Many patients who did not receive a novel diabetes medication during their hospitalization were at increased risk of cardiovascular, renal or heart failure events — and thus most likely to benefit from these medications. Yet instead of CV risk, the strongest factors associated with the use of these novel diabetes medications were elevated HbA1c and younger patient age.”
Researchers collected data from 68,126 adults with type 2 diabetes hospitalized at one of seven hospitals in the province of Ontario in Canada from 2015 to 2020. Prescriptions for GLP-1s and SGLT2 inhibitors during hospitalization were obtained. Researchers identified adults at risk for CVD, heart failure or renal failure based on medical history.
Of the study group, 3.7% were prescribed an SGLT2 inhibitor and 0.2% received a GLP-1 during hospitalization. Sulfonylureas were prescribed to 17.2% of adults.
Adults who had an HbA1c of more than 9% were more likely to be prescribed an SGLT2 or GLP-1 drug than those with an HbA1c of less than 6.5% (OR = 1.81; 95% CI, 1.28-2.6). Adults aged 40 to 60 years had higher odds for receiving a novel diabetes drug than those younger than 40 years (OR = 1.81; 95% CI, 1.33-2.68). Men were more likely to receive an SGLT2 or GLP-1 than women (OR = 1.36; 95% CI, 1.23-1.52), and cardiologists were more likely than other attending health care professionals to prescribe a novel diabetes medication (OR = 1.47; 95% CI, 1.23-1.75).
Adults with a creatinine level of 200 µmol or higher (OR = 0.11; 95% CI, 0.08-0.15), heart failure (OR = 0.76; 95% CI, 0.65-0.89) or dementia (OR = 0.47; 95% CI, 0.39-0.56) were less likely to receive an SGLT2 or GLP-1. Adults were also less likely to be prescribed a novel diabetes drug if their attending physician was a nephrologist (OR = 0.26; 95% CI, 0.08-0.62).
Of adults who did not receive an SGLT2 inhibitor or GLP-1, 46.8% had a history of coronary artery disease, stroke, transient ischemic attack, peripheral vascular disease, heart failure or renal failure. Many of the studies confirming CV and renal benefits of SGLT2 inhibitors and GLP-1s were published after 2020.
“The results of this study can help to inform strategies to increase utilization of novel medications when appropriate, and to target efforts to ensure patients are receiving medications that have real benefits for them, especially high-risk, vulnerable populations who, owing to inherent biases in medical practice, can be excluded from these therapies,” the researchers wrote.
Future research should examine interventions and strategies to educate health care professionals and people with diabetes about SGLT2 inhibitors and GLP-1s, according to the researchers.
Perspective
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This study underscores the underutilization of SGLT2 inhibitors and GLP-1s in hospitalized patients with type 2 diabetes, despite their established cardiovascular, renal and glycemic benefits. Alarmingly, fewer than 5% of eligible patients received these medications prior to discharge, even though nearly half had significant CV or renal risks.
Cardiologists were among the strongest predictors of novel medication use, likely reflecting their familiarity with the CV benefits of these therapies. In contrast, endocrinologists were notably absent from the analysis, likely grouped under “other” specialties. This may reflect that most endocrinologists practice primarily in outpatient settings, highlighting a gap in specialized inpatient diabetes management.
Barriers such as cost further hinder utilization. GLP-1s remain expensive, and many hospital formularies likely do not stock these medications. The use of SGLT2 inhibitors in hospitals is also controversial due to the risk for diabetic ketoacidosis (Cohen B, et al. Endocr Pract. 2024;doi:10.1016/j.eprac.2023.11.014). As an endocrine hospitalist, I prescribe SGLT2 inhibitors only when discharge is anticipated within 24 to 48 hours to mitigate this risk, while prioritizing these therapies for patients with obesity, CVD or renal failure (Demidowich AP, et al. Diabetes Spectr. 2022;doi:10.2337/dsi22-0013).
Addressing physician awareness, cost and formulary limitations is critical to ensuring high-risk patients receive these transformative therapies to improve outcomes.
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