This cohort study evaluates the use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagonlike peptide-1 receptor agonists (GLP-1 RA) in adults with type 2 diabetes and atherosclerotic cardiovascular disease across a diverse sample of health care systems in the US.
Key Points
Question
What is the contemporary use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagonlike peptide-1 receptor agonists (GLP-1 RA) among US adults with type 2 diabetes and atherosclerotic cardiovascular disease in the US following updates to major society recommendations?
Findings
In this cohort study of longitudinal health care system data from 321 304 adults with atherosclerotic cardiovascular disease and type 2 diabetes taking glucose-lowering therapy across 88 US health care systems, use of SGLT2i and GLP-1 RA increased from 2018 to 2021.
Meaning
In this study, despite increases in use of both SGLT2i and GLP-1 RA, the majority of patients with atherosclerotic cardiovascular disease receiving medical therapy for type 2 diabetes were not taking either.
Abstract
Importance
Recent national guidelines recommend sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagonlike peptide-1 receptor agonists (GLP-1 RA) in patients with type 2 diabetes (T2D) and atherosclerotic cardiovascular disease (ASCVD); yet, there are limited data on the use of these agents in contemporary community practice.
Objective
To evaluate the use of SGLT2i and GLP-1 RA in adults with T2D and ASCVD across a diverse sample of health care systems in the US.
Design, Setting, and Participants
This multicenter, retrospective cohort study used electronic health record data from 88 US health care systems participating in Cerner Real World Data between January 2018 to March 2021. Adults with ASCVD and T2D taking at least 1 glucose-lowering medication, had end-stage kidney disease, or had stage 5 chronic kidney disease were excluded.
Main Outcomes and Measures
Treatment with SGLT2i or GLP-1 RA.
Results
A total of 321 304 patients were identified with T2D and ASCVD ASCVD (130 280 female [40.5%]; median [IQR] age, 70.9 [62.9-78.0] years) who were potentially eligible for SGLT2i and/or GLP-1 RA, including 37 754 Black individuals (11.8%), 51 522 Hispanic individuals (16.0%), and 256 008 White individuals (11.8%). From January 2018 to March 2021, the use of SGLT2i increased from 5.8% (11 285 of 194 264) to 12.9% (11 058 of 85 956), GLP-1 RA increased from 6.9% (13 402 of 194 264) to 13.8% (11 901 of 85 956), and use of either agent increased from 11.4% (22 069 of 194 264) to 23.2% (19 909 of 85 956). Those taking an SGLT2i or GLP-1 RA were younger, less frequently hospitalized in the year prior, and more likely to be taking additional secondary prevention medications. Treated and nontreated populations were similar in terms of race, ethnicity, and outpatient health care utilization. Sulfonylureas and dipeptidyl peptidase 4 inhibitors remained more commonly used than SGLT2i or GLP-1 RA through 2021.
Conclusions and Relevance
In this study, uptake of SGLT2i and GLP-1 RA in adults with T2D and ASCVD increased modestly after guideline recommendations, although less than a quarter of persons with ASCVD and T2D receiving medical therapy were taking either. Further efforts are necessary to maximize the potential population benefit of these therapies in this high-risk population.
Introduction
Individuals with type 2 diabetes (T2D) carry a high risk of developing atherosclerotic cardiovascular disease (ASCVD) and experience worse associated outcomes.1,2 Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagonlike peptide-1 receptor agonists (GLP-1 RA) are glucose-lowering medications that have demonstrated cardiovascular benefits across multiple large randomized clinical trials in patients with T2D with established or at high risk for ASCVD.3 Given this accumulating evidence, multiple major societies have been updating recommendations in recent years with strong directives for the use of these glucose-lowering agents with proven cardiovascular benefits.4,5,6 Older studies demonstrated low early use of SGLT2i and GLP-1 RA.7,8,9,10,11,12,13 Whether uptake of these agents has improved with early adoption of these recommendations is unknown.
Methods
We sought to determine whether contemporary use of SGLT2i and GLP-1 RA has improved in the US since the release of these major society recommendations in a representative population of patients for whom these medications were developed (those with ASCVD and T2D receiving medical therapy), across a large diverse population. Cerner Real World Data includes longitudinal electronic health record (EHR) data from all available EHR vendors at participating health care systems across the US. This includes patient demographics (including race and ethnicity), diagnosis and procedure data from inpatient, outpatient, and emergency department visits, and medication data that are either self-reported or prescribed through the EHR. Comorbidities are defined by diagnosis codes on patient problem lists or linked to encounters. We analyzed data from 88 health care systems from January 2018 through March 2021. Data were analyzed longitudinally to evaluate trends in medication use among eligible adults by quarter. In each quarter, inclusion criteria were (1) adults (age ≥18 years); (2) at least 1 outpatient visit in that quarter (if multiple visits, the last visit in the quarter was used); (3) updated medication data; (4) prevalent ASCVD (coronary artery disease, peripheral arterial disease, or atherosclerotic cerebrovascular disease and prevalent T2D [diagnosis on or prior to the last visit]); and (5) taking at least 1 glucose-lowering medication. Patients with any prior diagnosis of chronic kidney disease stage 5 or end-stage kidney disease were excluded. Patients with longitudinal follow-up could be included in multiple quarters but only once per quarter. Trends in the use of SGLT2i, GLP-1 RA, metformin, sulfonylureas, dipeptidyl peptidase 4 inhibitors (DPP-4i), thiazolidinediones, and insulin were assessed. We also evaluated temporal trends stratified by the presence of heart failure with reduced ejection fraction (HFrEF), geographic region, and insurance status.
To assess contemporary patterns of use, patient demographics, comorbidities, medication history, and vitals were summarized according to treatment status with an SGLT2i or GLP-1 RA based on each person’s last encounter with the health care system between January 2020 through March 2021, with standardized mean differences used to compare differences between groups. Data management and statistical analyses were conducted in Python version 3.7, Spark version 2.4 (Apache), and R version 4.0 (R Foundation).
Results
A total of 321 304 patients (130 280 female [40.5%]; median [IQR] age, 70.9 [62.9-78.0] years; median [IQR] follow-up, 2.1 [1.0-2.9] years) were included in the analysis, including 37 754 Black individuals (11.8%), 51 522 Hispanic individuals (16.0%), and 256 008 White individuals (11.8%). The use of SGLT2i and GLP-1 RA increased from January 2018 through March 2021 (SGLT2i: from 5.8% [11 285 of 194 264] to 12.9% [11 058 of 85 956]; GLP-1 RA: from 6.9% [13 402 of 194 264] to 13.8% [11 901 of 85 956]; Cochran-Armitage test for trend <.001 for both GLP-1 RA and SGLT2i; Figure 1). Combined, the percentage of patients with T2D and ASCVD taking either agent increased from 11.4% (22 069 of 194 264) in 2018 and to 23.2% (19 909 of 85 956) in 2021. Metformin use was relatively unchanged over this time (60.4% [117 272 of 194 264] in 2018 vs 61.1% [52 514 of 85 956] in 2021). Use of other noncardiovascular glucose-lowering agents variably decreased, including sulfonylureas (29.8% [57 860 of 194 264] to 25.6% [21 982 of 85 956]), DPP-4i (17.3% [33 584 of 194 264] to 16.9% [14 523 of 85 956]), and thiazolidinediones (4.8% [9323 of 194 264] to 4.4% [3815 of 85 956]), although both sulfonylureas and DPP-4i remained more commonly used than SGLT2i or GLP-1 RAs through March 2021.
Figure 1. Trends in Medication Use Among Patients With Atherosclerotic Cardiovascular Disease and Diabetes, 2018-2021.
Within a given quarter, only patients with at least 1 diabetes medication record have been included. DPP-4i indicates dipeptidyl peptidase 4 inhibitors; GLP-1 RA, glucagonlike peptide-1 receptor agonist; SGLT2i, sodium-glucose cotransporter 2 inhibitor.
The Table summarizes patient characteristics by those taking SGLT2i or GLP-1 RA and those not receiving therapy for their most recent available encounter from 2018 to 2021. Treated and nontreated populations were generally similar in terms of race and ethnicity, but there were sex differences in treatment with female individuals less frequently treated with SGLT2i. Compared with nontreated individuals, patients treated with SGLT-2i or GLP-1 RA were younger, weighed more, were less frequently hospitalized in the preceding year, had slightly higher hemoglobin A1c levels, and were more likely to be taking additional secondary prevention medications. The prevalence of patients being seen at academic centers was similar among those treated vs not treated. Stratification by the presence and absence of HFrEF demonstrated generally similar rates of use of SGLT2i and GLP-1 RA among those with and without HFrEF over time, although SGLT2i use did appear to become more common among those with HFrEF by 2021 (13.9% [1515 of 10 887] vs 12.7% [9541 of 75 069]; Figure 2A). There were subtle differences observed in treatment rates by geographic region, with those in the Southwest US having the lowest treatment rates for both SGLT2i and GLP-1 RA (Figure 2B). Individuals with private insurance had the highest treatment rates for both GLP-1 RA and SGLT2i, and those with Medicare had consistently low treatment rates (Figure 2C). Finally, increasing access to care as measured by the number of outpatient encounters in the past year was associated with treatment with GLP1-RA but not SGLT2i.
Table. Patient Characteristics of Those Treated With GLP-1 RA or SGLT2i vs Not Treated.
| Characteristic | GLP-1 RA last visit | SGLT2i last visit | ||||||
|---|---|---|---|---|---|---|---|---|
| No. (%) | P valuea | SMDa | No. (%) | P valuea | SMDa | |||
| Taking GLP-1 RA (n = 34 477) | Not taking GLP-1 RA (n = 286 827) | Taking SGLT2i (n = 31 043) | Not taking SGLT2i (n = 290 261) | |||||
| Age | ||||||||
| Median (IQR), y | 66.4 (59.3-73.1) | 71.4 (63.4-78.5) | <.001 | 0.44 | 66.0 (59.1-72.5) | 71.4 (63.4-78.5) | <.001 | 0.47 |
| Sex | ||||||||
| Female | 14 625 (42.4) | 115 655 (40.3) | <.001 | 0.05 | 10 083 (32.5) | 120 197 (41.4) | <.001 | 0.19 |
| Male | 19 603 (56.9) | 169 770 (59.2) | 20 765 (66.9) | 168 608 (58.1) | ||||
| Other/unknown | 249 (0.7) | 1402 (0.5) | 195 (0.6) | 1456 (0.5) | ||||
| Race | ||||||||
| American Indian or Alaska Native | 218 (0.6) | 1828 (0.6) | <.001 | 0.05 | 125 (0.4) | 1921 (0.7) | <.001 | 0.08 |
| Asian or Pacific islander | 509 (1.5) | 5595 (2.0) | 700 (2.3) | 5404 (1.9) | ||||
| Black or African American | 4315 (12.5) | 33 439 (11.7) | 3079 (9.9) | 34 675 (11.9) | ||||
| Multiracial | 63 (0.2) | 799 (0.3) | 57 (0.2) | 805 (0.3) | ||||
| White | 27 555 (79.9) | 228 453 (79.6) | 25 259 (81.4) | 230 749 (79.5) | ||||
| Otherb | 811 (2.4) | 8152 (2.8) | 884 (2.8) | 8079 (2.8) | ||||
| Unknown | 1006 (2.9) | 8561 (3.0) | 939 (3.0) | 8628 (3.0) | ||||
| Ethnicity | ||||||||
| Hispanic or Latino | 5058 (14.7) | 46 464 (16.2) | <.001 | 0.04 | 5593 (18.0) | 45 929 (15.8) | <.001 | 0.06 |
| Not Hispanic or Latino | 28 496 (82.7) | 233 119 (81.3) | 24 618 (79.3) | 236 997 (81.6) | ||||
| Unknown | 923 (2.7) | 7244 (2.5) | 832 (2.7) | 7335 (2.5) | ||||
| Insurance | ||||||||
| Government | 292 (0.8) | 3026 (1.1) | <.001 | 0.2 | 312 (1.0) | 3006 (1.0) | <.001 | 0.29 |
| Medicaid | 1489 (4.3) | 12 151 (4.2) | 1432 (4.6) | 12 208 (4.2) | ||||
| Medicare | 12 368 (35.9) | 120 413 (42.0) | 10 614 (34.2) | 122 167 (42.1) | ||||
| Missing | 12 499 (36.3) | 103 600 (36.1) | 10 561 (34.0) | 105 538 (36.4) | ||||
| None | 1666 (4.8) | 13 601 (4.7) | 1530 (4.9) | 13 737 (4.7) | ||||
| Other | 323 (0.9) | 3153 (1.1) | 300 (1.0) | 3176 (1.1) | ||||
| Private | 5840 (16.9) | 30 883 (10.8) | 6294 (20.3) | 30 429 (10.5) | ||||
| Geographic region | ||||||||
| Midwest | 7716 (22.4) | 60 660 (21.1) | <.001 | 0.19 | 6909 (22.3) | 61 467 (21.2) | <.001 | 0.23 |
| Northeast | 7642 (22.2) | 67 174 (23.4) | 7496 (24.1) | 67 320 (23.2) | ||||
| South | 4149 (12.0) | 31 784 (11.1) | 4363 (14.1) | 31 570 (10.9) | ||||
| South East | 9645 (28.0) | 64 852 (22.6) | 7536 (24.3) | 66 961 (23.1) | ||||
| Southwest | 3175 (9.2) | 39 533 (13.8) | 2265 (7.3) | 40 443 (13.9) | ||||
| West Coast | 2150 (6.2) | 22 824 (8.0) | 2474 (8.0) | 22 500 (7.8) | ||||
| Weight, kg | ||||||||
| No. (%) | 29 137 (84.5) | 236 567 (82.5) | <.001 | 0.41 | 25 976 (83.7) | 239 728 (82.6) | <.001 | 0.2 |
| Median (IQR) | 98.0 (84.0-115.0) | 88.0 (75.0-104.0) | 94.0 (80.0-110.0) | 89.0 (75.0-105.0) | ||||
| Hemoglobin A1c, % | ||||||||
| No. (%) | 19 261 (55.9) | 150 624 (52.5) | <.001 | 0.18 | 17 124 (55.2) | 152 761 (52.6) | <.001 | 0.19 |
| Median (IQR) | 7.5 (6.7-8.7) | 7.1 (6.3-8.2) | 7.6 (6.8-8.7) | 7.1 (6.3-8.2) | ||||
| Prior MI | 8101 (23.5) | 75 098 (26.2) | <.001 | 0.06 | 7665 (24.7) | 75 534 (26.0) | <.001 | 0.03 |
| Prior stroke/TIA | 5492 (15.9) | 57 720 (20.1) | <.001 | 0.11 | 4433 (14.3) | 58 779 (20.3) | <.001 | 0.16 |
| Any PAD | 8934 (25.9) | 79 250 (27.6) | <.001 | 0.04 | 7407 (23.9) | 80 777 (27.8) | <.001 | 0.09 |
| CKD | 9752 (28.3) | 83 364 (29.1) | .003 | 0.02 | 5634 (18.1) | 87 482 (30.1) | <.001 | 0.28 |
| Hospitalizations in past year, mean (SD) | 0.5 (1.3) | 0.8 (1.7) | <.001 | 0.19 | 0.5 (1.2) | 0.8 (1.7) | <.001 | 0.22 |
| Outpatient encounters in past year, mean (SD) | 13.2 (13.2) | 11.8 (12.6) | <.001 | 0.11 | 12.0 (11.8) | 12.0 (12.7) | .96 | <0.001 |
| Hypertension | 32 119 (93.2) | 264 825 (92.3) | <.001 | 0.03 | 28 579 (92.1) | 268 365 (92.5) | .01 | 0.02 |
| Atrial fibrillation | 6103 (17.7) | 66 852 (23.3) | <.001 | 0.14 | 5237 (16.9) | 67 718 (23.3) | <.001 | 0.17 |
| Heart failure, any | 9907 (28.7) | 95 507 (33.3) | <.001 | 0.1 | 8512 (27.4) | 96 902 (33.4) | <.001 | 0.13 |
| Heart failure with reduced ejection fraction | 3776 (11.0) | 39 396 (13.7) | <.001 | 0.09 | 3704 (11.9) | 39 468 (13.6) | <.001 | 0.05 |
| SGLT2i | 8175 (23.7) | 22 868 (8.0) | <.001 | 0.44 | 31 043 (100) | 0 (0) | <.001 | NA |
| GLP-1 RA | 34 477 (100) | 0 (0) | <.001 | NA | 8175 (26.3) | 26 302 (9.1) | <.001 | 0.47 |
| Any statin | 28 835 (83.6) | 225 002 (78.4) | <.001 | 0.13 | 26 430 (85.1) | 227 407 (78.3) | <.001 | 0.18 |
| High statin | 14 714 (42.7) | 105 796 (36.9) | <.001 | 0.12 | 14 325 (46.1) | 106 185 (36.6) | <.001 | 0.20 |
| Ezetimibe | 2671 (7.7) | 14 568 (5.1) | <.001 | 0.11 | 2722 (8.8) | 14 517 (5.0) | <.001 | 0.15 |
| PCSK9 | 714 (2.1) | 2536 (0.9) | <.001 | 0.10 | 666 (2.1) | 2584 (0.9) | <.001 | 0.10 |
| ACEI/ARB | 24 775 (71.9) | 186 515 (65.0) | <.001 | 0.15 | 23 071 (74.3) | 188 219 (64.8) | <.001 | 0.21 |
| β-Blocker | 23 160 (67.2) | 187 421 (65.3) | <.001 | 0.04 | 21 073 (67.9) | 189 508 (65.3) | <.001 | 0.06 |
| Aspirin | 22 217 (64.4) | 178 128 (62.1) | <.001 | 0.05 | 20 823 (67.1) | 179 522 (61.8) | <.001 | 0.11 |
| P2Y12 inhibitor | 9587 (27.8) | 77 942 (27.2) | .01 | 0.01 | 9517 (30.7) | 78 012 (26.9) | <.001 | 0.08 |
| Insulin | 20 044 (58.1) | 126 036 (43.9) | <.001 | 0.29 | 13 599 (43.8) | 132 481 (45.6) | <.001 | 0.04 |
| Metformin | 19 554 (56.7) | 168 822 (58.9) | <.001 | 0.04 | 21 203 (68.3) | 167 173 (57.6) | <.001 | 0.22 |
| Sulfonylureas | 8195 (23.8) | 74 972 (26.1) | <.001 | 0.06 | 8841 (28.5) | 74 326 (25.6) | <.001 | 0.07 |
| Thiazolidinediones | 2256 (6.5) | 12 005 (4.2) | <.001 | 0.10 | 2234 (7.2) | 12 027 (4.1) | <.001 | 0.13 |
| DPP-4 inhibitors | 3745 (10.9) | 49 573 (17.3) | <.001 | 0.19 | 7066 (22.8) | 46 252 (15.9) | <.001 | 0.17 |
| Center type | ||||||||
| Academic | 3907 (11.3) | 30 333 (10.6) | <.001 | 0.04 | 3508 (11.3) | 30 732 (10.6) | <.001 | 0.03 |
| Community hospital | 1284 (3.7) | 12 605 (4.4) | 1268 (4.1) | 12 621 (4.3) | ||||
| Pediatric | 1 (0.0) | 8 (0.0) | 1 (0.0) | 8 (0.0) | ||||
| Regional/IDN | 29 285 (84.9) | 243 881 (85.0) | 26 266 (84.6) | 246 900 (85.1) | ||||
| Bed size | ||||||||
| 0-49 | 587 (1.7) | 5242 (1.8) | <.001 | 0.13 | 529 (1.7) | 5300 (1.8) | <.001 | 0.16 |
| 50-99 | 355 (1.0) | 3523 (1.2) | 362 (1.2) | 3516 (1.2) | ||||
| 100-499 | 4541 (13.2) | 38 987 (13.6) | 4030 (13.0) | 39 498 (13.6) | ||||
| 500-999 | 12 958 (37.6) | 92 809 (32.4) | 12 165 (39.2) | 93 602 (32.2) | ||||
| ≥1000 | 15 986 (46.4) | 144 480 (50.4) | 13 888 (44.7) | 146 578 (50.5) | ||||
| Missing | 50 (0.1) | 1786 (0.6) | 69 (0.2) | 1767 (0.6) | ||||
| Last encounter year | ||||||||
| 2018 | 1705 (4.9) | 32 280 (11.3) | NA | NA | 1453 (4.7) | 32 532 (11.2) | NA | NA |
| 2019 | 4075 (11.8) | 53 358 (18.6) | 3307 (10.7) | 54 126 (18.6) | ||||
| 2020 | 18 321 (53.1) | 137 140 (47.8) | 16 767 (54.0) | 138 694 (47.8) | ||||
| 2021 | 10 376 (30.1) | 64 049 (22.3) | 9516 (30.7) | 64 909 (22.4) | ||||
Abbreviations: ACEI/ARB, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker; CKD, chronic kidney disease; DPP-4, dipeptidyl peptidase 4; GLP-1 RA, glucagonlike peptide-1 receptor agonist; IDN, integrated delivery network; MI, myocardial infarction; NA, not applicable; PAD, peripheral arterial disease; SGLT2i, sodium-glucose cotransporter 2 inhibitor; SMD, standardized mean difference; TIA, transient ischemic attack.
SI conversion factors: To convert hemoglobin A1c to proportion of 1.0, multiply by 0.01.
P values and SMD for sex, race, and ethnicity do not include missing or unknown categories.
Patients were classified as other if they did not fall under one of the other race categories.
Figure 2. Temporal Trends in Glucagonlike Peptide-1 Receptor Agonist (GLP-1 RA) and Sodium-Glucose Cotransporter 2 Inhibitor (SGLT2i).
Trends in GLP-1 RA and SGLT2i use stratified by the presence and absence of HFrEF (A), by geographic region (B), and by insurance type (C).
Discussion
We examine SGLT2i and GLP-1 RA use in individuals with ASCVD and T2D across a broad, diverse population of US adults receiving health care since the release of these updated major society recommendations. We found that from 2018 to 2021, use of both SGLT2i and GLP-1 RA increased gradually. However, as recently as March 2021, most individuals with ASCVD and T2D receiving medication therapy were not taking either SGLT2i or GLP-1 RA. Furthermore, 2 glucose-lowering therapies without proven cardiovascular benefit, namely sulfonylureas and DPP-4i, continue to be used more frequently than either SGLT2i or GLP-1 RA.
SGLT2i and GLP-1 RA both have demonstrated substantial benefits in adults with ASCVD. Randomized clinical trials demonstrate a similar treatment effect for both SGLT2i and GLP-1 RA in those with diabetes and established ASCVD, with a 14% reduction in the hazard of major adverse cardiovascular events observed with both agents.14,15 Based on these data, the American Diabetes Association has recommended SGLT2i and GLP-1 RA as first-line agents for individuals with T2D and ASCVD after metformin since 2019.4 Similarly, the 2018 American College of Cardiology Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients with T2D and ASCVD recommended that clinicians consider the addition of an SGLT2i or GLP-1 RA in patients with T2D and established clinical ASCVD, a recommendation that was reinforced in 2020.5,6 In the wake of these updates, we found that the use of SGLT2i and GLP-1 RA both approximately doubled from January 2018 through March 2021, while the percentage of potentially eligible patients taking at least 1 of the agents increased from just over 1 in 10 to nearly a quarter. Despite these improvements, agents without clinical outcome benefits (sulfonylureas and DPP-4i) continue to be used more frequently than either SGLT2i or GLP-1 RA.
Reasons for continued underuse of these evidence-based therapies are likely multifactorial and include the relatively higher cost of new therapies as well as clinical inertia by prescribing physicians. For example, treatment rates were highest among those with private insurance and lowest among Medicare beneficiaries, who may face the highest out-of-pocket costs for new therapies. Health care utilization measured by outpatient visits was higher in those taking an SGLT2i or GLP-1 RA, perhaps due to increasing opportunities for medication changes. Female individuals were less frequently treated with SGLT2i, highlighting yet another area of sex-based treatment differences in cardiovascular care. Clinicians may be focused on controlling hemoglobin A1c at the expense of prescribing agents with clinical outcome benefits; we did observe modestly higher hemoglobin A1c levels among those treated with SGLT2i and GLP-1 RA. Center-level factors may also play a role; while there were no clear treatment differences associated with type of center (academic vs community), we did observe geographic variation in treatment rates, with the Southwest US having the lowest treatment rates for both SGLT2i and GLP-1 RA. Despite data showing benefit for SGLT2i in persons with HFrEF during the study period,3 uptake of SGLT2i was not higher among those with HFrEF until 2021, suggesting that the uptake in HFrEF was not sufficient to change overall prescribing patterns compared with the broader population of those with T2D and ASCVD until recently.
Limitations
This analysis has some limitations. First, medication data were obtained from prescription orders and patient self-report rather than prescription fill data. Second, while the early increase in treatment with both SGLT2i and GLP-1 RA following the release of recent guideline updates is encouraging, future analyses will be necessary to determine the long-term temporal trends in prescription patterns triggered by these recommendations. Finally, the use of EHR data precludes our ability to determine the specific clinical rationale underlying treatment decisions.
Conclusions
Despite the room for improvement, our findings also support cautious optimism around efforts to increase the uptake of SGLT2i and GLP-1 RA in clinical practice: treatment rates have more than doubled from 2018 through 2021. To continue this momentum, creative implementation science approaches will be necessary to further increase the use of these safe and effective medications in individuals with T2D and ASCVD.
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