Patterns of Medication Use and Prescription Fills for Cardioprotective Anti-Hyperglycemic Agents in the United States

ImportanceSelected glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium glucose cotransporter-2 inhibitors (SGLT2i) have cardioprotective effects in patients with type 2 diabetes and elevated cardiovascular risk. Prescription of these agents by clinicians and their consistent use by patients are essential to realize their benefits. ObjectiveTo assess the patterns of use and prescription fills of GLP-1RAs and SGLT-2i. DesignCross-sectional for medication use and prospective for prescription fills in 2018-2020 SettingNationwide de-identified US administrative claims database of Medicare Advantage and commercially insured adults. ParticipantsIndividuals 18 years of age and older with type 2 diabetes ExposuresComorbidities representing guideline-directed indications of atherosclerotic cardiovascular disease (ASCVD) for GLP-1RAs, and ASCVD, heart failure, and diabetic nephropathy for SGLT2i. Main Outcomes and MeasuresMedication use and monthly fill rates for 12 months following initiation of therapy by calculating the proportion of days with consistent medication use. ResultsAmong 587,657 individuals with type 2 diabetes, 80,196 (13.6%) were prescribed GLP-1RAs and 68,149 (11.5%) SGLT2i during 2018-2020. This represented 12.9% and 10.5% of individuals with indications for each medication, respectively. Based on monthly counts of new prescriptions, there were no changes in the uptake of either drug class during 2019-2020. Among new initiators, fill rate was 52.5% for GLP-1RAs and 52.9% for SGLT2i one year after initiation. One-year fill rates were higher for patients with commercial insurance than those with Medicare Advantage plans for both GLP-1RAs (59.3% vs 51.0%, p-value<0.001) and SGLT2i (63.4% vs 50.3%, p-value<0.001). After adjusting for comorbidity profile, there were higher prescription fills for patients with commercial insurance (versus Medicare Advantage, OR 1.17, 95% CI [1.06-1.29] for GLP-1RAs, and 1.59 [1.42-1.77] for SGLT2i); and higher income (top quartile versus others, OR 1.09 [1.06-1.12] for GLP-1RAs, and 1.06 [1.03-1.10] for SGLT2i). Conclusions and RelevanceIn 2018-2020, use of GLP-1RAs and SGLT2i remained limited to fewer than 1 in 8 individuals with type 2 diabetes meeting criteria for evidence-based guideline and professional society recommendations, with one-year fill rates around 50%. The low and inconsistent use of these medications compromises their longitudinal health outcomes benefits in a period of expanding indications for their use.