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Lussier ME, Desai RJ, Wright EA, Gionfriddo MR. Impact of cost on prescribing diabetes medications for older adults with type 2 diabetes in the outpatient setting. Res Social Adm Pharm 2024; 20:755-759. [PMID: 38697890 DOI: 10.1016/j.sapharm.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Newer diabetes medications have cardiorenal benefits beyond blood sugar lowering that make them a preferred treatment option in many patients. Despite this, studies have shown that prescribing of these medications remains suboptimal with medication costs being hypothesized as a reason for underutilization. OBJECTIVE To understand clinicians' decision-making processes for prescribing diabetes medications in older adults, focusing on higher cost medications. METHODS Observations of patient encounters and semi-structured interviews were conducted with clinicians from primary care, endocrinology, and geriatrics to elucidate themes into diabetes medication prescribing. A qualitative descriptive approach was used to analyze the data from interviews using an inductive coding scheme with themes derived from the data. RESULTS Twenty-one interviews were conducted. Five themes were identified: 1) out-of-pocket costs drive prescribing decisions 2) out-of-pocket costs can be variable due to changing insurance plans or changing coverage 3) clinicians have difficulty with determining patient-specific out-of-pocket costs 4) clinicians manage the tradeoffs existing between cost, efficacy, and safety and 5) clinicians can use cost-modifying strategies such as patient assistance. CONCLUSION Addressing the challenges that medication costs pose to prescribing evidence-based medications for type 2 diabetes is necessary to optimize diabetes care for older adults.
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Affiliation(s)
- Mia E Lussier
- Geisinger, Center for Pharmacy Innovation and Outcomes, 100 North Academy Avenue, Danville, PA, USA; Binghamton University, School of Pharmacy and Pharmaceutical Sciences, PO Box 6000, Binghamton, NY, 13902-6000, USA.
| | - Ravi J Desai
- Geisinger, Center for Pharmacy Innovation and Outcomes, 100 North Academy Avenue, Danville, PA, USA
| | - Eric A Wright
- Geisinger, Center for Pharmacy Innovation and Outcomes, 100 North Academy Avenue, Danville, PA, USA
| | - Michael R Gionfriddo
- Duquesne University, Division of Pharmaceutical, Administrative, and Social Sciences, 600 Forbes Avenue, Pittsburgh, PA, 15282, USA
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de Oliveira Costa J, Lin J, Milder TY, Greenfield JR, Day RO, Stocker SL, Neuen BL, Havard A, Pearson SA, Falster MO. Geographic variation in sodium-glucose cotransporter 2 inhibitor and glucagon-like peptide-1 receptor agonist use in people with type 2 diabetes in New South Wales, Australia. Diabetes Obes Metab 2024; 26:2787-2795. [PMID: 38618983 DOI: 10.1111/dom.15597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
AIM Sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) improve glycaemic control and cardio-renal outcomes for people with type 2 diabetes (T2D). However, geographic and socio-economic variation in use is not well understood. METHODS We identified 367 829 New South Wales residents aged ≥40 years who dispensed metformin in 2020 as a proxy for T2D. We estimated the prevalence of use of other glucose-lowering medicines among people with T2D and the prevalence of SGLT2i and GLP-1RA use among people using concomitant T2D therapy (i.e. metformin + another glucose-lowering medicine). We measured the prevalence by small-level geography, stratified by age group, and characterized by remoteness and socio-economic status. RESULTS The prevalence of SGLT2i (29.7%) and GLP-1RA (8.3%) use in people with T2D aged 40-64 increased with geographic remoteness and in areas of greater socio-economic disadvantage, similar to other glucose-lowering medicines. The prevalence of SGLT2i (55.4%) and GLP-1RA (15.4%) among people using concomitant T2D therapy varied across geographic areas, with lower SGLT2i use in more disadvantaged areas and localized areas of high GLP-1RA use (2.5 times the median). Compared with people aged 40-64 years, the prevalence of SGLT2i and GLP-1RA use was lower in older age groups, but with similar patterns of variation across geographic areas. CONCLUSIONS The prevalence of SGLT2i and GLP-1RA use varied by geography, probably reflecting a combination of system- and prescriber-level factors. Socio-economic variation in GLP-1RA use was overshadowed by localized patterns of prescribing. Continued monitoring of variation can help shape interventions to optimize use among people who would benefit the most.
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Affiliation(s)
- Juliana de Oliveira Costa
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jialing Lin
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Tamara Y Milder
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Alys Havard
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Sallie-Anne Pearson
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael O Falster
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
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Scheen AJ. Underuse of GLP-1 receptor agonists in the management of type 2 diabetes despite a favorable benefit-safety profile. Expert Opin Drug Saf 2024; 23:797-810. [PMID: 38738549 DOI: 10.1080/14740338.2024.2354885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 05/09/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Patients with type 2 diabetes (T2DM) are at high risk of atherosclerotic cardiovascular disease (ASCVD) and cardiovascular death. Cardiovascular protection is a key objective in T2DM. AREAS COVERED Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have proven their efficacy in reducing major cardiovascular events in high-risk patients with T2DM in placebo-controlled trials, a finding confirmed in observational studies compared with other glucose-lowering agents. Overall, GLP-1RAs have a good safety profile associated with a favorable benefit/risk ratio for the management of T2DM, even if their cost-effectiveness might be questionable. International guidelines recommend GLP-1RAs as preferred glucose-lowering agents in patients with ASCVD and as a valuable alternative in overweight/obese patients with T2DM. However, real-life studies worldwide revealed that only a minority of patients receive a GLP-1RA, despite a positive trend for increased prescriptions in recent years. Surprisingly, however, fewer patients with established ASCVD are treated with these cardioprotective antihyperglycemic agents versus patients without ASCVD. EXPERT OPINION The reasons for GLP-1RA underuse in clinical practice are multiple. Multifaceted and coordinated interventions targeting all actors of the health-care system must be implemented to stimulate the adoption of GLP-1RAs as part of routine cardiovascular care among patients with T2DM, especially in those with ASCVD.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, CHU Liège, Liège, Belgium
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium
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Rodriguez LA, Finertie H, Neugebauer RS, Gosiker B, Thomas TW, Karter AJ, Gilliam LK, Oshiro C, An J, Simonson G, Cassidy-Bushrow AE, Dombrowski S, Nolan M, O'Connor PJ, Schmittdiel JA. Race and ethnicity and pharmacy dispensing of SGLT2 inhibitors and GLP-1 receptor agonists in type 2 diabetes. LANCET REGIONAL HEALTH. AMERICAS 2024; 34:100759. [PMID: 38745886 PMCID: PMC11091531 DOI: 10.1016/j.lana.2024.100759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/16/2024] [Accepted: 04/22/2024] [Indexed: 05/16/2024]
Abstract
Background Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2i) and Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RA) improve cardiorenal outcomes in patients with type 2 diabetes. Equitable use of SGLT2i and GLP-1 RA has the potential to reduce racial and ethnic health disparities. We evaluated trends in pharmacy dispensing of SGLT2i and GLP-1 RA by race and ethnicity. Methods Retrospective cohort study of patients (≥18 years) with type 2 diabetes using 2014-2022 electronic health record data from six US care delivery systems. Entry was at earliest pharmacy dispensing of any type 2 diabetes medication. We used multivariable logistic regression to evaluate the association between pharmacy dispensing of SGLT2i and GLP1-RA and race and ethnicity. Findings Our cohort included 687,165 patients (median 6 years of dispensing data; median 60 years; 0.3% American Indian/Alaska Native (AI/AN), 16.6% Asian, 10.5% Black, 1.4% Hawaiian or Pacific Islander (HPI), 31.1% Hispanic, 3.8% Other, and 36.3% White). SGLT2i was lower for AI/AN (OR 0.80, 95% confidence interval 0.68-0.94), Black (0.89, 0.86-0.92) and Hispanic (0.87, 0.85-0.89) compared to White patients. GLP-1 RA was lower for AI/AN (0.78, 0.63-0.97), Asian (0.50, 0.48-0.53), Black (0.86, 0.83-0.90), HPI (0.52, 0.46-0.57), Hispanic (0.69, 0.66-0.71), and Other (0.78, 0.73-0.83) compared to White patients. Interpretation Dispensing of SGLT2is, and GLP-1 RAs was lower in minority group patients. There is a need to evaluate approaches to increase use of these cardiorenal protective drugs in patients from racial and ethnic minority groups with type 2 diabetes to reduce adverse cardiorenal outcomes and improve health equity. Funding Patient-Centered Outcomes Research Institute and National Institutes of Health.
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Affiliation(s)
- Luis A. Rodriguez
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA
- University of California, Department of Epidemiology & Biostatistics, San Francisco, CA, USA
| | - Holly Finertie
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, USA
| | - Romain S. Neugebauer
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA
| | - Bennett Gosiker
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA
| | - Tainayah W. Thomas
- Stanford University School of Medicine, Department of Epidemiology and Population Health, Palo Alto, CA, USA
| | - Andrew J. Karter
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, USA
| | | | - Caryn Oshiro
- Kaiser Permanente Center for Integrated Health Care Research, Honolulu, HI, USA
| | - Jaejin An
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Gregg Simonson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN, USA
| | | | | | - Margaret Nolan
- HealthPartners Institute for Medical Education and Research, Bloomington, MN, USA
| | - Patrick J. O'Connor
- HealthPartners Institute for Medical Education and Research, Bloomington, MN, USA
| | - Julie A. Schmittdiel
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA
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Wo E, Trulli C, Wilczynski J, Gonzalez J. Evaluation of Sodium-Glucose Transport Protein 2 (SGLT2) Inhibitor Prescribing Patterns in Heart Failure Patients at Hospital Discharge. J Pharm Pract 2024:8971900241256772. [PMID: 38803216 DOI: 10.1177/08971900241256772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) dapagliflozin and empagliflozin are indicated for heart failure with reduced ejection fraction (HFrEF) for cardiovascular death and heart failure hospitalization risk reduction. Due to the recent nature of these data, prescribing of SGLT2is may be suboptimal. Objective: This study sought to assess the prevalence of SGLT2i prescriptions at hospital discharge for HFrEF. Methods: A retrospective chart review was conducted on HFrEF patients discharged from April 1st to December 31st, 2021 from one academic medical center in the United States. The primary objective was to determine the percentage of eligible patients prescribed SGLT2i at discharge and the secondary objective was to characterize covariates impacting prescription. Results: Overall, 115 patients were included. The mean age was 72 ± 14.25 years. The majority were male (73.9%) and Caucasian (74.8%). At discharge, 15.7% of patients were prescribed an SGLT2i, although 94.8% were eligible. Baseline characteristics and concomitant medications did not differ significantly, although the mean number of discharge medications differed significantly between those prescribed an SGLT2i (15.78 ± 6.77) and those not (12.05 ± 5.28) (P = 0.023). Conclusions: SGLT2is are under-prescribed at discharge for HFrEF patients, despite many being eligible. Further studies should be done to elucidate factors that influence the under-prescription of SGLT2is.
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Affiliation(s)
- Emily Wo
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | | | - Jessica Wilczynski
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
- Department of Pharmacy, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Jimmy Gonzalez
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
- Department of Pharmacy, Jersey Shore University Medical Center, Neptune, NJ, USA
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6
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Adamou A, Barkas F, Milionis H, Ntaios G. Glucagon-like peptide-1 receptor agonists and stroke: A systematic review and meta-analysis of cardiovascular outcome trials. Int J Stroke 2024:17474930241253988. [PMID: 38676552 DOI: 10.1177/17474930241253988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
BACKGROUND In patients surviving stroke, approximately 15% and 60% exhibit concurrent diabetes mellitus and overweight/obesity, respectively, necessitating heightened secondary prevention efforts. Despite glucagon-like peptide-1 receptor agonists (GLP-1 RAs) demonstrating improved outcomes for those with diabetes mellitus or obesity, their underutilization persists among eligible individuals. This systematic review and meta-analysis investigated the impact of GLP-1 RAs on stroke risk. The findings aim to optimize the implementation of this therapeutic strategy in patients surviving stroke with diabetes mellitus or obesity. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we systematically reviewed MEDLINE and Scopus until 15 November 2023. Eligible studies included randomized cardiovascular outcome trials (CVOTs) with individuals, with or without type 2 diabetes, randomized to either GLP-1 RA or placebo. The outcomes were total strokes, non-fatal strokes, and fatal strokes. Analyses were conducted using RevMan 5.4.1. RESULTS Among 1369 screened studies, 11 were eligible, encompassing 82,140 participants (34.6% women) with a cumulative follow-up of 247,596 person-years. In the GLP-1 RAs group, the stroke rate was significantly lower compared to placebo (RR: 0.85, 95% CI: 0.77-0.93; NNT: 200), showing no heterogeneity or interaction with administration frequency (daily vs weekly). In addition, the GLP-1 RAs group exhibited a significantly lower rate of non-fatal strokes compared to placebo (RR: 0.87, 95% CI: 0.79-0.95; NNT: 250), with no heterogeneity or interaction based on administration frequency, route (oral vs subcutaneous), or diabetes presence. CONCLUSION In this meta-analysis of 11 CVOTs with 82,140 participants, GLP-1 RAs demonstrated a 16% relative reduction in stroke risk compared to placebo. This finding may increase implementation of GLP-1 RAs by stroke specialists in individuals with stroke and comorbid diabetes mellitus or obesity. DATA ACCESS STATEMENT The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Affiliation(s)
- Anastasia Adamou
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- First Department of Propaedeutic Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Fotios Barkas
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Yang PJ, Wang PH, Huang JY, Lee CY, Lin CW, Lee CY, Yang SF. The lower incidence of endometrial cancer after sodium-glucose cotransporter 2 inhibitors administration in type 2 diabetes mellitus population: a nationwide cohort study. Int J Med Sci 2024; 21:1408-1413. [PMID: 38903923 PMCID: PMC11186417 DOI: 10.7150/ijms.95584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/17/2024] [Indexed: 06/22/2024] Open
Abstract
The Sodium-glucose co-transporter 2 (SGLT2) inhibitor is an anti-glycemic agent that frequently used in type 2 diabetes mellitus (T2DM) with antioxidant effects. Endometrial cancer (EC) is a common gynecological malignancy that correlates with oxidative stress. The aim in the present study is to survey the potential association between the SGLT2 inhibitor administration and the incidence of EC by the application of the National Health Insurance Research Database (NHIRD) of Taiwan. A retrospective cohort study was directed and the T2DM participants were divided into the SGLT2 inhibitors users and non-SGLT2 inhibitors users. After matching, a total of 163,668 and 327,336 participants were included into the SGLT2 inhibitors and control groups, respectively. The primary outcome is regarded as the development of EC according to the diagnostic, image, and procedure codes. Cox proportional hazard regression was employed to generate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) of EC between the two groups. There were 422 and 876 EC events observed in the SGLT2 inhibitors and control groups, respectively. The SGLT2 inhibitors group demonstrated a significantly lower incidence of EC formation compared to the control groups (aHR: 0.87, 95% CI: 0.76-0.99). In the subgroup analysis, the correlation between SGLT2 inhibitor administration and lower rate of EC existed in the T2DM individuals with aged under 60. Moreover, the association between SGLT2 inhibitor administration and lower EC incidence only presented in the T2DM population with SGLT2 inhibitor administration under one year (aHR: 0.58, 95% CI: 0.45-0.73). In conclusion, the administration of SGLT2 inhibitors correlates to lower incidence of EC in T2DM population.
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Affiliation(s)
- Po-Jen Yang
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Family and Community Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Po-Hui Wang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Jing-Yang Huang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chia-Yi Lee
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Ophthalmology, Nobel Eye Institute, Taipei, Taiwan
| | - Chiao-Wen Lin
- Institute of Oral Sciences, Chung Shan Medical University, Taichung, Taiwan
| | - Chung-Yuan Lee
- Department of Obstetrics and Gynecology, Chiayi Chang Gung Memorial Hospital Chiayi, Taiwan
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
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Osude N, Pagidipati NJ. A New Age for Secondary Prevention: Optimal Medical Therapy for Stable Ischemic Heart Disease Among Patients with Diabetes and/or Obesity. Med Clin North Am 2024; 108:469-487. [PMID: 38548458 DOI: 10.1016/j.mcna.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Patients with type 2 diabetes and/or obesity and established cardiovascular disease are at increased risk for recurrent cardiovascular events. The indications of glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors have been expanded in the last decade due to benefit in cardiovascular outcome trials and are now considered guideline-recommended therapy for patients with type 2 diabetes and cardiovascular disease. Emerging data have begun to suggest that GLP-1RAs can decrease major adverse cardiovascular events among patients with obesity without diabetes. Overall, prescription of these agents remains low, despite being key to improve disparities in recurrent cardiovascular events. In this review, we discuss optimal medical therapy for secondary prevention for stable ischemic heart disease.
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Affiliation(s)
- Nkiru Osude
- Cardiovascular Division, Duke University, 2301 Erwin Road, Durham, NC 27710, USA.
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Alshaya OA, Korayem GB, Alghwainm M, Alyami W, Alotaibi A, Alyami MS, Almohammed OA. The prevalence of cardiovascular diseases, chronic kidney disease, and obesity in patients with type 2 diabetes mellitus and the description of concurrent treatments: A two-center retrospective cross-sectional study in Saudi Arabia. Saudi Pharm J 2024; 32:102054. [PMID: 38590611 PMCID: PMC10999870 DOI: 10.1016/j.jsps.2024.102054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/27/2024] [Indexed: 04/10/2024] Open
Abstract
Background Atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), chronic kidney disease (CKD), and obesity are associated with increased morbidity and mortality in patients with type 2 diabetes mellitus (T2DM). Nonetheless, their prevalence among patients with T2DM in Saudi Arabia (SA) remains unknown. As current guidelines recommend, these comorbidities require adding certain antidiabetic agents with cardiorenal benefits. However, the prescribers' adherence to these recommendations remains unclear. Methods A two-center retrospective cross-sectional study was conducted including adult patients (≥18 years) with T2DM admitted to hospital or seen at outpatient clinics between January and December 2020. Patients were classified into two groups based on the presence or absence of ASCVD. Patients with no prior ASCVD history were further classified based on the 10-year ASCVD risk estimation. Endpoints of interest included the prevalence of ASCVD, HF, CKD, and obesity in patients with T2DM. We also evaluated the characteristics of the utilized antidiabetic agents, statin, and aspirin therapies.. Results Of the 1,218 included patients with T2DM, the majority were female (57.0 %), and aged 45-64 years (53.0 %) with a mean age of 59.3 ± 13.1 years. Hypertension and dyslipidemia were the most prevalent comorbidities (67.7 % and 69.0 %, respectively). Among all patients, 18.6 % had an established ASCVD and the prevalence of HF, CKD, and obesity were 5.1 %, 8.7 %, and 58.3 %, respectively. The most common types of ASCVD witnessed were revascularization (42.3 %), myocardial infarction (36.6 %), and stroke (33.9 %); with an increased prevalence of ASCVD as the age increases (52.8 % at age ≥ 65 years). In the non-ASCVD group, the 10-year ASCVD risk was intermediate or high in 62.7 % of these patients. The rates of utilization of guidelines-recommended therapies were 83.6 % for metformin, 9.4 % for GLP-1 RA, 10.8 % for SGLT2i, 35.2 % for aspirin alone or in combination with clopidogrel, and 79.7 % for statin therapy. Conclusions ASCVD, HF, CKD, and obesity are common complications in patients with T2DM in SA, with low overall utilization of the recommended guidelines-recommended medical therapies. Multimodal strategies should be utilized to assess T2DM and its complications, and to improve prescribers' adherence to guidelines-recommended therapies.
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Affiliation(s)
- Omar A. Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ghazwa B. Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University P.O.Box 84428, Riyadh 11671, Saudi Arabia
| | - Munirah Alghwainm
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Wed Alyami
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Albandari Alotaibi
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Majed S. Alyami
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Omar A. Almohammed
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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10
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Bogannam AR, McNicol E, DeLeonardo K, Ranade A, Zaiken K. Impact of American Diabetes Association 2022 Guidelines on Prescribing Rates of Sodium-Glucose Cotransporter-2 Inhibitors in Ambulatory Care Organization Patients With Type 2 Diabetes. J Pharm Pract 2024:8971900241247658. [PMID: 38647229 DOI: 10.1177/08971900241247658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Background: Recent clinical trials and guideline updates have highlighted the efficacy and safety of sodium-glucose cotransporter-2 inhibitor (SGLT2i) use in patients with type 2 diabetes (T2D) and comorbidities including atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), or heart failure (HF). Objective: This study assesses the rates of guideline-based prescribing of SGLT2i in patients with T2D and one or more of the following comorbidities: ASCVD, CKD, or HF, prior to and after the 2022 American Diabetes Association (ADA) guideline publication within the Atrius Health clinical pharmacy, internal medicine, and specialty medicine departments. Methods: This is a retrospective chart review of data from the electronic medical record. Patients with the aforementioned criteria were included if they were managed by either the clinical pharmacy department, internal medicine, or specialty medicine departments. Patients were excluded if they did not have any of the comorbidities listed or a form of diabetes other than T2D. Results: Of the 10,631 patients enrolled, 354 (3.3%) were initiated on an SGLT2i during the study. The average number of SGLT2i initiations prior to the 2022 ADA guideline publication was five prescription starts per week. After the guideline publication initiation increased to seven prescription starts per week. Secondary outcomes showed the majority of SGLT2i prescriptions were started in the internal medicine department, followed by cardiology and nephrology. Conclusion: Overall utilization rates of SGLT2i are low but increased after the 2022 ADA guidelines were published. These results suggest opportunities to optimize the use of SGLT2i in this patient population.
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Affiliation(s)
- Alexis R Bogannam
- Department of Clinical Pharmacy, Beth Israel Lahey Health, Wakefield, MA, USA
| | - Ewan McNicol
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA
| | - Kevin DeLeonardo
- Department of Clinical Pharmacy, Atrius Health, Watertown, MA, USA
| | - Ashwini Ranade
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA
| | - Kathy Zaiken
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA
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11
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Blood AJ, Chang LS, Colling C, Stern G, Gabovitch D, Feldman G, Adan A, Waterman F, Durden E, Hamersky C, Noone J, Aronson SJ, Liberatore P, Gaziano TA, Matta LS, Plutzky J, Cannon CP, Wexler DJ, Scirica BM. Methods, rationale, and design for a remote pharmacist and navigator-driven disease management program to improve guideline-directed medical therapy in patients with type 2 diabetes at elevated cardiovascular and/or kidney risk. Prim Care Diabetes 2024; 18:202-209. [PMID: 38302335 DOI: 10.1016/j.pcd.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 11/24/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
AIM Describe the rationale for and design of Diabetes Remote Intervention to improVe use of Evidence-based medications (DRIVE), a remote medication management program designed to initiate and titrate guideline-directed medical therapy (GDMT) in patients with type 2 diabetes (T2D) at elevated cardiovascular (CV) and/or kidney risk by leveraging non-physician providers. METHODS An electronic health record based algorithm is used to identify patients with T2D and either established atherosclerotic CV disease (ASCVD), high risk for ASCVD, chronic kidney disease, and/or heart failure within our health system. Patients are invited to participate and randomly assigned to either simultaneous education and medication management, or a period of education prior to medication management. Patient navigators (trained, non-licensed staff) are the primary points of contact while a pharmacist or nurse practitioner reviews and authorizes each medication initiation and titration under an institution-approved collaborative drug therapy management protocol with supervision from a cardiologist and/or endocrinologist. Patient engagement is managed through software to support communication, automation, workflow, and standardization. CONCLUSION We are testing a remote, navigator-driven, pharmacist-led, and physician-overseen management strategy to optimize GDMT for T2D as a population-level strategy to close the gap between guidelines and clinical practice for patients with T2D at elevated CV and/or kidney risk.
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Affiliation(s)
- Alexander J Blood
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Lee-Shing Chang
- Endocrinology Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Caitlin Colling
- Endocrinology Division, Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Gretchen Stern
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Gabovitch
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | - Guinevere Feldman
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | - Asma Adan
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | | | - Samuel J Aronson
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Personalized Medicine, Mass General Brigham, Cambridge, MA, USA
| | - Paul Liberatore
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Personalized Medicine, Mass General Brigham, Cambridge, MA, USA
| | - Thomas A Gaziano
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lina S Matta
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | - Jorge Plutzky
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Christopher P Cannon
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Deborah J Wexler
- Endocrinology Division, Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Benjamin M Scirica
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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12
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Kullgren JT, Kim HM, Slowey M, Colbert J, Soyster B, Winston SA, Ryan K, Forman JH, Riba M, Krupka E, Kerr EA. Using Behavioral Economics to Reduce Low-Value Care Among Older Adults: A Cluster Randomized Clinical Trial. JAMA Intern Med 2024; 184:281-290. [PMID: 38285565 PMCID: PMC10825788 DOI: 10.1001/jamainternmed.2023.7703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/22/2023] [Indexed: 01/31/2024]
Abstract
Importance Use of low-value care is common among older adults. It is unclear how to best engage clinicians and older patients to decrease use of low-value services. Objective To test whether the Committing to Choose Wisely behavioral economic intervention could engage primary care clinicians and older patients to reduce low-value care. Design, Setting, and Participants Stepped-wedge cluster randomized clinical trial conducted at 8 primary care clinics of an academic health system and a private group practice between December 12, 2017, and September 4, 2019. Participants were primary care clinicians and older adult patients who had diabetes, insomnia, or anxiety or were eligible for prostate cancer screening. Data analysis was performed from October 2019 to November 2023. Intervention Clinicians were invited to commit in writing to Choosing Wisely recommendations for older patients to avoid use of hypoglycemic medications to achieve tight glycemic control, sedative-hypnotic medications for insomnia or anxiety, and prostate-specific antigen tests to screen for prostate cancer. Committed clinicians had their photographs displayed on clinic posters and received weekly emails with alternatives to these low-value services. Educational handouts were mailed to applicable patients before scheduled visits and available at the point of care. Main Outcomes and Measures Patient-months with a low-value service across conditions (primary outcome) and separately for each condition (secondary outcomes). For patients with diabetes, or insomnia or anxiety, secondary outcomes were patient-months in which targeted medications were decreased or stopped (ie, deintensified). Results The study included 81 primary care clinicians and 8030 older adult patients (mean [SD] age, 75.1 [7.2] years; 4076 men [50.8%] and 3954 women [49.2%]). Across conditions, a low-value service was used in 7627 of the 37 116 control patient-months (20.5%) and 7416 of the 46 381 intervention patient-months (16.0%) (adjusted odds ratio, 0.79; 95% CI, 0.65-0.97). For each individual condition, there were no significant differences between the control and intervention periods in the odds of patient-months with a low-value service. The intervention increased the odds of deintensification of hypoglycemic medications for diabetes (adjusted odds ratio, 1.85; 95% CI, 1.06-3.24) but not sedative-hypnotic medications for insomnia or anxiety. Conclusions and Relevance In this stepped-wedge cluster randomized clinical trial, the Committing to Choose Wisely behavioral economic intervention reduced low-value care across 3 common clinical situations and increased deintensification of hypoglycemic medications for diabetes. Use of scalable interventions that nudge patients and clinicians to achieve greater value while preserving autonomy in decision-making should be explored more broadly. Trial Registration ClinicalTrials.gov Identifier: NCT03411525.
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Affiliation(s)
- Jeffrey T. Kullgren
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
- University of Michigan Center for Bioethics and Social Sciences in Medicine, Ann Arbor
| | - H. Myra Kim
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
| | - Megan Slowey
- Center for Health and Research Transformation, Ann Arbor, Michigan
| | - Joseph Colbert
- University of Michigan Center for Bioethics and Social Sciences in Medicine, Ann Arbor
| | - Barbara Soyster
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | | | - Kerry Ryan
- University of Michigan Center for Bioethics and Social Sciences in Medicine, Ann Arbor
| | - Jane H. Forman
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Melissa Riba
- Center for Health and Research Transformation, Ann Arbor, Michigan
| | - Erin Krupka
- University of Michigan School of Information, Ann Arbor
| | - Eve A. Kerr
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
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13
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Deo SV, Al-Kindi S, Motairek I, McAllister D, Shah ASV, Elgudin YE, Gorodeski EZ, Virani S, Petrie MC, Rajagopalan S, Sattar N. Impact of Residential Social Deprivation on Prediction of Heart Failure in Patients With Type 2 Diabetes: External Validation and Recalibration of the WATCH-DM Score Using Real World Data. Circ Cardiovasc Qual Outcomes 2024; 17:e010166. [PMID: 38328913 DOI: 10.1161/circoutcomes.123.010166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 11/20/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Patients with type 2 diabetes are at risk of heart failure hospitalization. As social determinants of health are rarely included in risk models, we validated and recalibrated the WATCH-DM score in a diverse patient-group using their social deprivation index (SDI). METHODS We identified US Veterans with type 2 diabetes without heart failure that received outpatient care during 2010 at Veterans Affairs medical centers nationwide, linked them to their SDI using residential ZIP codes and grouped them as SDI <20%, 21% to 40%, 41% to 60%, 61% to 80%, and >80% (higher values represent increased deprivation). Accounting for all-cause mortality, we obtained the incidence for heart failure hospitalization at 5 years follow-up; overall and in each SDI group. We evaluated the WATCH-DM score using the C statistic, the Greenwood Nam D'Agostino test χ2 test and calibration plots and further recalibrated the WATCH-DM score for each SDI group using a statistical correction factor. RESULTS In 1 065 691 studied patients (mean age 67 years, 25% Black and 6% Hispanic patients), the 5-year incidence of heart failure hospitalization was 5.39%. In SDI group 1 (least deprived) and 5 (most deprived), the 5-year heart failure hospitalization was 3.18% and 11%, respectively. The score C statistic was 0.62; WATCH-DM systematically overestimated heart failure risk in SDI groups 1 to 2 (expected/observed ratios, 1.38 and 1.36, respectively) and underestimated the heart failure risk in groups 4 to 5 (expected/observed ratios, 0.95 and 0.80, respectively). Graphical evaluation demonstrated that the recalibration of WATCH-DM using an SDI group-based correction factor improved predictive capabilities as supported by reduction in the χ2 test results (801-27 in SDI groups I; 623-23 in SDI group V). CONCLUSIONS Including social determinants of health to recalibrate the WATCH-DM score improved risk prediction highlighting the importance of including social determinants in future clinical risk prediction models.
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Affiliation(s)
- Salil V Deo
- Surgical Services, Louis Stokes Cleveland VA Medical Center, Cleveland, OH (S.V.D., Y.E.E.)
- Case School of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH (S.V.D., Y.E.E., E.Z.G., S.R.)
- School of Health and Wellbeing (S.V.D., D.M.), University of Glasgow, United Kingdom
| | - Sadeer Al-Kindi
- Division of Cardiovascular Prevention and Wellness, DeBakey Heart and Vascular Center, Houston Methodist, Houston, TX (S.A.-K.)
| | - Issam Motairek
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH (I.M., E.Z.G., S.R.)
| | - David McAllister
- School of Health and Wellbeing (S.V.D., D.M.), University of Glasgow, United Kingdom
| | - Anoop S V Shah
- London School of Hygiene and Tropical Medicine, London, United Kingdom (A.S.V.S.)
| | - Yakov E Elgudin
- Surgical Services, Louis Stokes Cleveland VA Medical Center, Cleveland, OH (S.V.D., Y.E.E.)
- Case School of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH (S.V.D., Y.E.E., E.Z.G., S.R.)
| | - Eiran Z Gorodeski
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH (I.M., E.Z.G., S.R.)
| | - Salim Virani
- The Aga Khan University, Karachi, Pakistan (S.V.)
- Division of Cardiology, Baylor School of Medicine, Houston, TX (S.V.)
| | - Mark C Petrie
- BHF Cardiovascular Research Center, School of Cardiovascular and Metabolic Health (M.C.P., N.S.), University of Glasgow, United Kingdom
- Robertson Center for Biostatistics (M.C.P.), University of Glasgow, United Kingdom
| | - Sanjay Rajagopalan
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH (I.M., E.Z.G., S.R.)
| | - Naveed Sattar
- BHF Cardiovascular Research Center, School of Cardiovascular and Metabolic Health (M.C.P., N.S.), University of Glasgow, United Kingdom
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14
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Lussier ME, Gionfriddo MR, Graham JH, Wright EA. Factors Affecting Prescribing of Type 2 Diabetes Medications in Older Adults within an Integrated Healthcare System. J Gen Intern Med 2024; 39:195-200. [PMID: 37783983 PMCID: PMC10853133 DOI: 10.1007/s11606-023-08435-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 09/15/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Despite type 2 diabetes guidelines recommending against the use of sulfonylureas in older adults and for the use of sodium-glucose cotransporter-2 inhibitors (SGLT2) and glucagon-like peptide-1 agonists (GLP1s) in patients with atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), and heart failure (HF), real-world guideline-concordant prescribing remains low. While some factors such as cost have been suggested, an in-depth analysis of the factors associated with guideline-concordant prescribing is warranted. OBJECTIVE To quantify the extent of guideline-concordant prescribing in an integrated health care delivery system and examine provider and patient level factors that influence guideline-concordant prescribing. DESIGN We performed a cross-sectional study. PARTICIPANTS Participants were included if they had a diagnosis of type 2 diabetes, were prescribed a second-line diabetes medication between January 1, 2018 and December 31, 2020 and were at least 65 years old at the time of this second-line prescription. MAIN MEASURES Our outcome of interest was guideline-concordant prescribing. The definition of guideline-concordant prescribing was based on American Diabetes Association and American Geriatric Society recommendations as well as expert consensus. Factors affecting guideline concordant prescribing included patient demographics and provider characteristics among others. KEY RESULTS We included 1,693 patients of which only 50% were prescribed guideline-concordant medications. In a subgroup of 843 patients with cardiorenal conditions, only 30% of prescriptions were guideline concordant. Prescribing of guideline-concordant prescriptions was more likely among pharmacists than physicians (RR 1.34, 95% CI 1.19-1.51, p<0.001) and in endocrinology practices compared to primary care practices (RR 1.41 95% CI 1.16-1.72, p=0.007). Additionally, guideline concordant prescribing increased over time (42% in 2018 vs 53% in 2019 vs 53% in 2020, p<0.001). CONCLUSIONS Guideline-concordant prescribing remains low in older adults, especially among those with cardiorenal conditions. Future studies should examine barriers to prescribing guideline-concordant medications and interventions to improve guideline-concordant prescribing.
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Affiliation(s)
- Mia E Lussier
- Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Danville, PA, USA.
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Johnson City, NY, USA.
| | - Michael R Gionfriddo
- Division of Pharmaceutical, Administrative, and Social Sciences, School of Pharmacy, Duquesne University, Pittsburgh, PA, USA
| | - Jove H Graham
- Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Danville, PA, USA
| | - Eric A Wright
- Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Danville, PA, USA
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15
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Kokkinos P, Nylen E, Faselis C, Pittaras A, Samuel IBH, Lavie C, Doumas M, Heimall MS, Murphy R, Myers J. Progression to Insulin Therapy in Patients With Type 2 Diabetes According to Cardiorespiratory Fitness, Body Mass Index, and Statin Therapy. Mayo Clin Proc 2024; 99:249-259. [PMID: 37389516 DOI: 10.1016/j.mayocp.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/17/2023] [Accepted: 05/01/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To evaluate the association between statin therapy, cardiorespiratory fitness (CRF), body mass index (BMI), and progression to insulin therapy in type 2 diabetes mellitus (T2DM). METHODS Participants were patients with T2DM (mean age, 62.7±8.4 years; men, 178,992; women, 8360) not treated with insulin, with no evidence of uncontrolled cardiovascular disease, who completed an exercise treadmill test between October 1, 1999, and September 3, 2020. Of these, 158,578 were treated with statins and 28,774 were not. We established 5 age-specific CRF categories according to peak metabolic equivalents of task achieved during an exercise treadmill test. RESULTS During a median follow-up period of 9.0 years, 51,182 patients progressed to insulin therapy with an average annual incidence rate of 28.4 events/1000 person-years. The adjusted progression rate was 27% higher in statin-treated patients (hazard ratio [HR], 1.27; 95% CI, 1.24 to 1.31), related directly to BMI and inversely related to CRF. A progressively higher rate was noted in statin-treated vs non-statin-treated patients within all BMI categories, ranging from 23% for normal weight to 90% for those with BMI of 35 kg/m2 and higher. The statin-CRF interaction revealed 43% higher rate in the least-fit statin-treated patients (HR, 1.43; 95% CI, 1.35 to 1.51) and a progressive decline with increased CRF to 30% lower risk in highly fit statin-treated patients (HR, 0.70; 95% CI, 0.66 to 0.75). CONCLUSION In patients with T2DM, the statin-related progression to insulin therapy was associated with relatively low CRF and high BMI levels. The progression rate was mitigated by increased CRF regardless of BMI. Clinicians should foster regular exercise for patients with T2DM to enhance CRF and to lessen the rate of progression to insulin therapy.
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Affiliation(s)
- Peter Kokkinos
- Veterans Affairs Medical Center, Washington, DC; Department of Kinesiology and Health, Rutgers University, New Brunswick, NJ; George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Eric Nylen
- Veterans Affairs Medical Center, Washington, DC; George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Charles Faselis
- Veterans Affairs Medical Center, Washington, DC; George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Andreas Pittaras
- Veterans Affairs Medical Center, Washington, DC; George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Immanuel Babu Henry Samuel
- Veterans Affairs Medical Center, Washington, DC; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Carl Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA
| | - Michael Doumas
- Veterans Affairs Medical Center, Washington, DC; Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | - Jonathan Myers
- Cardiology Division, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Department of Cardiology, Stanford University, Stanford, CA
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16
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Salahuddin T, Hebbe A, Daus M, Essien UR, Waldo SW, Rodriguez F, Ho PM, Simons C, Gilmartin HM, Doll JA. Trends and site-level variation of novel cardiovascular medication utilization among patients admitted for heart failure or coronary artery disease in the US Veterans Affairs System: 2017-2021. Am Heart J 2024; 268:68-79. [PMID: 37956920 DOI: 10.1016/j.ahj.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/18/2023] [Accepted: 11/04/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND We assessed trends in novel cardiovascular medication utilization in US Veterans Affairs (VA) for angiotensin receptor-neprilysin inhibitors (ARNI), sodium-glucose cotransporter-2 Inhibitors (SGLT2i), and glucagon-like peptide-1 receptor agonists (GLP-1 RA). METHODS We retrospectively identified cohorts from 114 VA hospitals with admission for prevalent 1) systolic heart failure (HF, N = 82,375) or 2) coronary artery disease and diabetes (CAD+T2D, N = 74,209). Site-level data for prevalent filled prescriptions were assessed at hospital admission, discharge, or within 6 months of discharge. Variability among sites was estimated with median odds ratios (mOR), and within-site Pearson correlations of utilization of each medication class were calculated. Site- and patient-level characteristics were compared by high-, mixed-, and low-utilizing sites. RESULTS ARNI and SGTL2i use for HF increased from <5% to 20% and 21%, respectively, while SGTL2i or GLP-1 RA use for CAD+T2D increased from <5% to 30% from 2017 to 2021. Adjusted mOR and 95% confidence intervals for ARNI, SGTL2i for HF, and SGTL2i or GLP-1 RA for CAD+T2D were 1.73 (1.64-1.91), 1.72 (1.59-1.81), and 1.53 (1.45-1.62), respectively. Utilization of each medication class correlated poorly with use of other novel classes (Pearson <0.38 for all). Higher patient volume, number of beds, and hospital complexity correlated with high-utilizing sites. CONCLUSIONS Utilization of novel medications has increased over time but remains suboptimal for US Veterans with HF and CAD+T2D, with substantial site-level heterogeneity despite a universal medication formulary and low out-of-pocket costs for patients. Future work should include further characterization of hospital- and clinician-level practice patterns to serve as targets to increase implementation.
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Affiliation(s)
- Taufiq Salahuddin
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA; VA Puget Sound Health Care System, Seattle, WA; Seattle-Denver Center of Innovation for Veteran-Centered and Value Driven Care, Veterans Health Administration Eastern Colorado Healthcare System, Aurora, CO
| | - Annika Hebbe
- VA Puget Sound Health Care System, Seattle, WA; Seattle-Denver Center of Innovation for Veteran-Centered and Value Driven Care, Veterans Health Administration Eastern Colorado Healthcare System, Aurora, CO; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
| | - Marguerite Daus
- VA Puget Sound Health Care System, Seattle, WA; Seattle-Denver Center of Innovation for Veteran-Centered and Value Driven Care, Veterans Health Administration Eastern Colorado Healthcare System, Aurora, CO; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO
| | - Utibe R Essien
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA; Center for the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA
| | - Stephen W Waldo
- VA Puget Sound Health Care System, Seattle, WA; Seattle-Denver Center of Innovation for Veteran-Centered and Value Driven Care, Veterans Health Administration Eastern Colorado Healthcare System, Aurora, CO; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, CA
| | - P Michael Ho
- VA Puget Sound Health Care System, Seattle, WA; Seattle-Denver Center of Innovation for Veteran-Centered and Value Driven Care, Veterans Health Administration Eastern Colorado Healthcare System, Aurora, CO
| | - Carol Simons
- VA Puget Sound Health Care System, Seattle, WA; Seattle-Denver Center of Innovation for Veteran-Centered and Value Driven Care, Veterans Health Administration Eastern Colorado Healthcare System, Aurora, CO
| | - Heather M Gilmartin
- VA Puget Sound Health Care System, Seattle, WA; Seattle-Denver Center of Innovation for Veteran-Centered and Value Driven Care, Veterans Health Administration Eastern Colorado Healthcare System, Aurora, CO; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO; Department of Health Systems, Management and Policy, University of Colorado School of Public Health, Aurora, CO
| | - Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA; VA Puget Sound Health Care System, Seattle, WA; Seattle-Denver Center of Innovation for Veteran-Centered and Value Driven Care, Veterans Health Administration Eastern Colorado Healthcare System, Aurora, CO; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC.
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17
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Chen WH, Li Y, Yang L, Allen JM, Shao H, Donahoo WT, Billelo L, Hu X, Shenkman EA, Bian J, Smith SM, Guo J. Geographic variation and racial disparities in adoption of newer glucose-lowering drugs with cardiovascular benefits among US Medicare beneficiaries with type 2 diabetes. PLoS One 2024; 19:e0297208. [PMID: 38285682 PMCID: PMC10824445 DOI: 10.1371/journal.pone.0297208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/30/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Prior studies have shown disparities in the uptake of cardioprotective newer glucose-lowering drugs (GLDs), including sodium-glucose cotranwsporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1a). This study aimed to characterize geographic variation in the initiation of newer GLDs and the geographic variation in the disparities in initiating these medications. METHODS Using 2017-2018 claims data from a 15% random nationwide sample of Medicare Part D beneficiaries, we identified individuals diagnosed with type 2 diabetes (T2D), who had ≥1 GLD prescriptions, and did not use SGLT2i or GLP1a in the year prior to the index date,1/1/2018. Patients were followed up for a year. The cohort was spatiotemporally linked to Dartmouth hospital-referral regions (HRRs), with each patient assigned to 1 of 306 HRRs. We performed multivariable Poisson regression to estimate adjusted initiation rates, and multivariable logistic regression to assess racial disparities in each HRR. RESULTS Among 795,469 individuals with T2D included in the analyses, the mean (SD) age was 73 (10) y, 53.3% were women, 12.2% were non-Hispanic Black, and 7.2% initiated a newer GLD in the follow-up year. In the adjusted model including clinical factors, compared to non-Hispanic White patients, non-Hispanic Black (initiation rate ratio, IRR [95% CI]: 0.66 [0.64-0.68]), American Indian/Alaska Native (0.74 [0.66-0.82]), Hispanic (0.85 [0.82-0.87]), and Asian/Pacific islander (0.94 [0.89-0.98]) patients were less likely to initiate newer GLDs. Significant geographic variation was observed across HRRs, with an initiation rate spanning 2.7%-13.6%. CONCLUSIONS This study uncovered substantial geographic variation and the racial disparities in initiating newer GLDs.
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Affiliation(s)
- Wei-Han Chen
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
| | - Yujia Li
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
| | - Lanting Yang
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - John M. Allen
- Department of Pharmacotherapy & Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
| | - Hui Shao
- Hubert Department of Global Health, Rollin School of Public Health, Emory University, Atlanta, Georgia, United States of America
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - William T. Donahoo
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Lori Billelo
- Office of Research Affairs, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, United States of America
| | - Xia Hu
- Department of Computer Science, Rice University, Houston, Texas, United States of America
| | - Elizabeth A. Shenkman
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Steven M. Smith
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
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Wisniewski B, Smith E, Kaur J, Sherling C, Vanapalli S, Lussier M. Medicare formulary restrictions for glucagon-like peptide 1 receptor agonists and sodium glucose cotransporter 2 inhibitors used in type 2 diabetes mellitus: 2019-2023. J Manag Care Spec Pharm 2024; 30:34-42. [PMID: 38153863 PMCID: PMC10775775 DOI: 10.18553/jmcp.2024.30.1.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
BACKGROUND Glucagon-like peptide 1 receptor agonists (GLP1-RAs) and sodium glucose cotransporter 2 inhibitors (SGLT2is) have proven benefits in patients with type 2 diabetes mellitus related to decreasing cardiovascular events and heart failure hospitalizations as well as preventing the progression of kidney disease. This led the American Diabetes Association (ADA) to update their guidelines in 2022 to recommend GLP1-RAs and SGLT2is as potential first-line options in patients with cardiorenal conditions. Formulary restrictions, such as step therapy and prior authorizations, can limit access to these beneficial medications. OBJECTIVE To evaluate trends in Medicare formulary restrictions of GLP1-RAs and SGLT2is following the recommendations by the ADA for first-line use. METHODS We conducted a retrospective cohort study of Quarter 1 Medicare formulary restrictions on GLP1-RAs and SGLT2is from 2019 to 2023. We analyzed changes in formulary restrictions by year, before and after the ADA first-line recommendations, single vs combination products, and products with and without other indications on a medication level (ie, each unique National Drug Code number on each unique formulary) and formulary level (ie, any prior authorization or step therapy requirements yield formulary restriction). RESULTS We analyzed 12,212 unique Medicare formularies. GLP1-RAs were 12.5% less likely (relative risk [RR] = 0.87; 95% CI = 0.84-0.91; P < 0.001) and 33.2% less likely (RR = 0.67; 95% CI = 0.60-0.74; P < 0.001) to have restrictions after the ADA guideline changes on a medication and formulary level, respectively. SGLT2is were 87.8% less likely (RR = 0.12; 95% CI = 0.11-0.13; P < 0.001) and 53.0% less likely (RR = 0.47; 95% CI = 0.27-0.80; P = 0.005) to have restrictions after the ADA guideline changes on medication and formulary levels, respectively. CONCLUSIONS Decreasing trends of medications and formularies with restrictions may indicate payers are recognizing GLP1-RAs and SGLT2is as potential first-line agents, aligning with ADA recommendations.
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Affiliation(s)
- Brady Wisniewski
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Johnson City, NY
| | - Eric Smith
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Johnson City, NY
| | - Jasmeen Kaur
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Johnson City, NY
| | - Ciara Sherling
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Johnson City, NY
| | - Shravani Vanapalli
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Johnson City, NY
| | - Mia Lussier
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Johnson City, NY
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19
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Yau K, Odutayo A, Dash S, Cherney DZI. Biology and Clinical Use of Glucagon-Like Peptide-1 Receptor Agonists in Vascular Protection. Can J Cardiol 2023; 39:1816-1838. [PMID: 37429523 DOI: 10.1016/j.cjca.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 07/12/2023] Open
Abstract
Glucagon-like peptide-1 receptor agonists (GLP1RA) are incretin agents initially designed for the treatment of type 2 diabetes mellitus but because of pleiotropic actions are now used to reduce cardiovascular disease in people with type 2 diabetes mellitus and in some instances as approved treatments for obesity. In this review we highlight the biology and pharmacology of GLP1RA. We review the evidence for clinical benefit on major adverse cardiovascular outcomes in addition to modulation of cardiometabolic risk factors including reductions in weight, blood pressure, improvement in lipid profiles, and effects on kidney function. Guidance is provided on indications and potential adverse effects to consider. Finally, we describe the evolving landscape of GLP1RA and including novel glucagon-like peptide-1-based dual/polyagonist therapies that are being evaluated for weight loss, type 2 diabetes mellitus, and cardiorenal benefit.
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Affiliation(s)
- Kevin Yau
- Department of Medicine, Division of Nephrology, University Health Network, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ayodele Odutayo
- Department of Medicine, Division of Nephrology, University Health Network, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Satya Dash
- Department of Medicine, Division of Nephrology, University Health Network, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, University Health Network, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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20
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Khera R, Dhingra LS, Aminorroaya A, Li K, Zhou JJ, Arshad F, Blacketer C, Bowring MG, Bu F, Cook M, Dorr DA, Duarte-Salles T, DuVall SL, Falconer T, French TE, Hanchrow EE, Horban S, Lau WCY, Li J, Liu Y, Lu Y, Man KKC, Matheny ME, Mathioudakis N, McLemore MF, Minty E, Morales DR, Nagy P, Nishimura A, Ostropolets A, Pistillo A, Posada JD, Pratt N, Reyes C, Ross JS, Seager S, Shah N, Simon K, Wan EYF, Yang J, Yin C, You SC, Schuemie MJ, Ryan PB, Hripcsak G, Krumholz H, Suchard MA. Multinational patterns of second line antihyperglycaemic drug initiation across cardiovascular risk groups: federated pharmacoepidemiological evaluation in LEGEND-T2DM. BMJ MEDICINE 2023; 2:e000651. [PMID: 37829182 PMCID: PMC10565313 DOI: 10.1136/bmjmed-2023-000651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/07/2023] [Indexed: 10/14/2023]
Abstract
Objective To assess the uptake of second line antihyperglycaemic drugs among patients with type 2 diabetes mellitus who are receiving metformin. Design Federated pharmacoepidemiological evaluation in LEGEND-T2DM. Setting 10 US and seven non-US electronic health record and administrative claims databases in the Observational Health Data Sciences and Informatics network in eight countries from 2011 to the end of 2021. Participants 4.8 million patients (≥18 years) across US and non-US based databases with type 2 diabetes mellitus who had received metformin monotherapy and had initiated second line treatments. Exposure The exposure used to evaluate each database was calendar year trends, with the years in the study that were specific to each cohort. Main outcomes measures The outcome was the incidence of second line antihyperglycaemic drug use (ie, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors, dipeptidyl peptidase-4 inhibitors, and sulfonylureas) among individuals who were already receiving treatment with metformin. The relative drug class level uptake across cardiovascular risk groups was also evaluated. Results 4.6 million patients were identified in US databases, 61 382 from Spain, 32 442 from Germany, 25 173 from the UK, 13 270 from France, 5580 from Scotland, 4614 from Hong Kong, and 2322 from Australia. During 2011-21, the combined proportional initiation of the cardioprotective antihyperglycaemic drugs (glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors) increased across all data sources, with the combined initiation of these drugs as second line drugs in 2021 ranging from 35.2% to 68.2% in the US databases, 15.4% in France, 34.7% in Spain, 50.1% in Germany, and 54.8% in Scotland. From 2016 to 2021, in some US and non-US databases, uptake of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors increased more significantly among populations with no cardiovascular disease compared with patients with established cardiovascular disease. No data source provided evidence of a greater increase in the uptake of these two drug classes in populations with cardiovascular disease compared with no cardiovascular disease. Conclusions Despite the increase in overall uptake of cardioprotective antihyperglycaemic drugs as second line treatments for type 2 diabetes mellitus, their uptake was lower in patients with cardiovascular disease than in people with no cardiovascular disease over the past decade. A strategy is needed to ensure that medication use is concordant with guideline recommendations to improve outcomes of patients with type 2 diabetes mellitus.
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Affiliation(s)
- Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Section of Health Informatics, Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
| | - Lovedeep Singh Dhingra
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Arya Aminorroaya
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Kelly Li
- Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Jin J Zhou
- Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Faaizah Arshad
- Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Clair Blacketer
- Observational Health Data Analytics, Janssen Research and Development, Titusville, NJ, USA
| | - Mary G Bowring
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fan Bu
- Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael Cook
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David A Dorr
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University School of Medicine, Portland, OR, USA
| | - Talita Duarte-Salles
- Real-World Epidemiology Research Group, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Scott L DuVall
- Veterans Affairs Informatics and Computing Infrastructure, United States Department of Veterans Affairs, Salt Lake City, UT, USA
- The University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Thomas Falconer
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - Tina E French
- Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth E Hanchrow
- Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott Horban
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Wallis CY Lau
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, China
| | - Jing Li
- Data Transformation, Analytics, and Artificial Intelligence, Real World Solutions, IQVIA Inc, Durham, NC, USA
| | - Yuntian Liu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Yuan Lu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Kenneth KC Man
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, China
| | - Michael E Matheny
- Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael F McLemore
- Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Evan Minty
- Faculty of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Daniel R Morales
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Paul Nagy
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Health Science Informatics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Akihiko Nishimura
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anna Ostropolets
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
| | - Andrea Pistillo
- Real-World Epidemiology Research Group, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Jose D Posada
- Systems Engineering and Computing, School of Engineering, Universidad del Norte, Barranquilla, Colombia
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Carlen Reyes
- Real-World Epidemiology Research Group, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Section of General Medicine and National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT, USA
| | - Sarah Seager
- Data Transformation, Analytics, and Artificial Intelligence, Real World Solutions, IQVIA Inc, Durham, NC, USA
| | - Nigam Shah
- Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, USA
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA, USA
- Technology and Digital Solutions, Stanford Health Care, Stanford, CA, USA
| | - Katherine Simon
- Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric YF Wan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, China
- Department of Family Medicine and Primary Care, School of Clinical Medicine, University of Hong Kong, Hong Kong, China
| | - Jianxiao Yang
- Department of Computational Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Can Yin
- Data Transformation, Analytics, and Artificial Intelligence, Real World Solutions, IQVIA Inc, Durham, NC, USA
| | - Seng Chan You
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea (aka South Korea)
- Institute for Innovation in Digital Healthcare, Yonsei University, Seoul, Republic of Korea (aka South Korea)
| | - Martijn J Schuemie
- Epidemiology, Office of the Chief Medical Officer, Johnson & Johnson, Titusville, NJ, USA
| | - Patrick B Ryan
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA
| | - Harlan Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT, USA
| | - Marc A Suchard
- Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
- Veterans Affairs Informatics and Computing Infrastructure, United States Department of Veterans Affairs, Salt Lake City, UT, USA
- Department of Biomathematics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Human Genetics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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21
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Nicholas SB, Daratha KB, Alicic RZ, Jones CR, Kornowske LM, Neumiller JJ, Fatoba ST, Kong SX, Singh R, Norris KC, Tuttle KR. Prescription of guideline-directed medical therapies in patients with diabetes and chronic kidney disease from the CURE-CKD Registry, 2019-2020. Diabetes Obes Metab 2023; 25:2970-2979. [PMID: 37395334 DOI: 10.1111/dom.15194] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/23/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023]
Abstract
AIM Guideline-directed medical therapy (GDMT) is designed to improve clinical outcomes. The study aim was to assess GDMT prescribing rates and prescribing-persistence predictors in patients with diabetes and chronic kidney disease (CKD) from the Center for Kidney Disease Research, Education, and Hope Registry. MATERIALS AND METHODS Data were obtained from adults ≥18 years old with diabetes and CKD between 1 January 2019 and 31 December 2020 (N = 39 158). Baseline and persistent (≥90 days) prescriptions for GDMT, including angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), sodium-glucose cotransporter-2 (SGLT2) inhibitor and glucagon-like peptide 1 (GLP-1) receptor agonist were assessed. RESULTS The population age (mean ± SD) was 70 ± 14 years, and 49.6% (n = 19 415) were women. Baseline estimated glomerular filtration rate (2021 CKD-Epidemiology Collaboration creatinine equation) was 57.5 ± 23.0 ml/min/1.73 m2 and urine albumin/creatinine 57.5 mg/g (31.7-158.2; median, interquartile range). Baseline and ≥90-day persistent prescribing rates, respectively, were 70.7% and 40.4% for ACE inhibitor/ARB, 6.0% and 5.0% for SGLT2 inhibitors, and 6.8% and 6.3% for GLP-1 receptor agonist (all p < .001). Patients lacking primary commercial health insurance coverage were less likely to be prescribed an ACE inhibitor/ARB [odds ratio (OR) = 0.89; 95% confidence interval (CI) 0.84-0.95; p < .001], SGLT2 inhibitor (OR 0.72; 95% CI 0.64-0.81; p < .001) or GLP-1 receptor agonist (OR 0.89; 95% CI 0.80-0.98; p = .02). GDMT prescribing rates were lower at Providence than UCLA Health. CONCLUSIONS Prescribing for GDMT was suboptimal and waned quickly in patients with diabetes and CKD. Type of primary health insurance coverage and health system were associated with GDMT prescribing.
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Affiliation(s)
- Susanne B Nicholas
- Nephrology Division, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Kenn B Daratha
- Providence Medical Research Center, Providence Inland Northwest, Spokane, Washington, USA
| | - Radica Z Alicic
- Providence Medical Research Center, Providence Inland Northwest, Spokane, Washington, USA
- Department of Medicine, University of Washington, Seattle, Spokane, Washington, USA
| | - Cami R Jones
- Providence Medical Research Center, Providence Inland Northwest, Spokane, Washington, USA
| | - Lindsey M Kornowske
- Providence Medical Research Center, Providence Inland Northwest, Spokane, Washington, USA
| | - Joshua J Neumiller
- Providence Medical Research Center, Providence Inland Northwest, Spokane, Washington, USA
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington, USA
| | | | | | - Rakesh Singh
- Bayer US, LLC, Medical Affairs, Whippany, Whippany, USA
| | - Keith C Norris
- Nephrology Division, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Inland Northwest, Spokane, Washington, USA
- Department of Medicine, University of Washington, Seattle, Spokane, Washington, USA
- Kidney Research Institute, Institute of Translational Health Sciences, University of Washington, Seattle, Washington, USA
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22
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Aroda VR, Billings LK. GLP-1 RA and SGLT2 Inhibitors: In Harmony for Organ Protection. J Am Coll Cardiol 2023; 82:526-528. [PMID: 37532423 DOI: 10.1016/j.jacc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Vanita R Aroda
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
| | - Liana K Billings
- Division of Endocrinology, NorthShore University HealthSystem, Skokie, Illinois, USA; Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA. https://twitter.com/lbillingsmd
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23
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Schwartz AL, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Radomski TR, Thorpe CT. Variation in Low-Value Service Use Across Veterans Affairs Facilities. J Gen Intern Med 2023; 38:2245-2253. [PMID: 36964425 PMCID: PMC10406760 DOI: 10.1007/s11606-023-08157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/10/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND It is unclear whether extensive variation in the use of low-value services exists even within a national integrated delivery system like the Veterans Health Administration (VA). OBJECTIVE To quantify variation in the use of low-value services across VA facilities and examine associations between facility characteristics and low-value service use. DESIGN In this retrospective cross-sectional study of VA administrative data, we constructed facility-level rates of low-value service use as the mean count of 29 low-value services per 100 Veterans per year. Adjusted rates were calculated via ordinary least squares regression including covariates for Veteran sociodemographic and clinical characteristics. We quantified the association between adjusted facility-level rates and facility geographic/operational characteristics. PARTICIPANTS 5,242,301 patients across 139 VA facilities. MAIN MEASURES Use of 29 low-value services within six domains: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and surgery. KEY RESULTS The mean rate of low-value service use was 20.0 services per 100 patients per year (S.D. 6.1). Rates ranged from 13.9 at the 10th percentile to 27.6 at the 90th percentile (90th/10th percentile ratio 2.0, 95% CI 1.8‒2.3). With adjustment for patient covariates, variation across facilities narrowed (S.D. 5.2, 90th/10th percentile ratio 1.8, 95% CI 1.6‒1.9). Only one facility characteristic was positively associated with low-value service use percent of patients seeing non-VA clinicians via VA Community Care, p < 0.05); none was associated with total low-value service use after adjustment for other facility characteristics. There was extensive variation in low-value service use within categories of facility operational characteristics. CONCLUSIONS Despite extensive variation in the use of low-value services across VA facilities, we observed substantial use of these services across facility operational characteristics and at facilities with lower rates of low-value service use. Thus, system-wide interventions to address low-value services may be more effective than interventions targeted to specific facilities or facility types.
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Affiliation(s)
- Aaron L Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, USA.
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Elijah Z Lovelace
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA
- Stanford Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford University, Stanford, CA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Charlotte, NC, USA
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Hussain A, Ramsey D, Lee M, Mahtta D, Khan MS, Nambi V, Ballantyne CM, Petersen LA, Walker AD, Kayani WT, Butler J, Slipczuk L, Rogers JG, Bozkurt B, Navaneethan SD, Virani SS. Utilization Rates of SGLT2 Inhibitors Among Patients With Type 2 Diabetes, Heart Failure, and Atherosclerotic Cardiovascular Disease: Insights From the Department of Veterans Affairs. JACC. HEART FAILURE 2023; 11:933-942. [PMID: 37204363 DOI: 10.1016/j.jchf.2023.03.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/20/2023] [Accepted: 03/31/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Multiple clinical trials have demonstrated significant cardiovascular benefit with use of sodium-glucose cotransporter-2 (SGLT2) inhibitors in patients with type 2 diabetes (T2DM) and heart failure (HF) irrespective of ejection fraction. There are limited data evaluating real-world prescription and practice patterns of SGLT2 inhibitors. OBJECTIVES The authors sought to assess utilization rates and facility-level variation in the use among patients with established atherosclerotic cardiovascular disease (ASCVD), HF, and T2DM using data from the nationwide Veterans Affairs health care system. METHODS The authors included patients with established ASCVD, HF, and T2DM seen by a primary care provider between January 1, 2020, and December 31, 2020. They assessed the use of SGLT2 inhibitors and the facility-level variation in their use. Facility-level variation was computed using median rate ratios, a measure of likelihood that 2 random facilities differ in use of SGLT2 inhibitors. RESULTS Among 105,799 patients with ASCVD, HF, and T2DM across 130 Veterans Affairs facilities, 14.6% received SGLT2 inhibitors. Patients receiving SGLT2 inhibitors were younger men with higher hemoglobin A1c and estimated glomerular filtration rate and were more likely to have HF with reduced ejection fraction and ischemic heart disease. There was significant facility-level variation of SGLT2 inhibitor use, with an adjusted median rate ratio of 1.55 (95% CI: 1.46-1.64), indicating a 55% residual difference in SGLT2 inhibitor use among similar patients with ASCVD, HF, and T2DM receiving care at 2 random facilities. CONCLUSIONS Utilization rates of SGLT2 inhibitors are low in patients with ASCVD, HF, and T2DM, with high residual facility-level variation. These findings suggest opportunities to optimize SGLT2 inhibitor use to prevent future adverse cardiovascular events.
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Affiliation(s)
- Aliza Hussain
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - David Ramsey
- Health Policy, Quality and Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA; Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Michelle Lee
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Dhruv Mahtta
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Vijay Nambi
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Christie M Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Laura A Petersen
- Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Adrienne D Walker
- Baylor Scott and White Research Institute, Baylor Scott and White, Dallas, Texas, USA
| | - Waleed T Kayani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Baylor Scott and White, Dallas, Texas, USA; Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA
| | - Leandro Slipczuk
- Cardiology Division, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Joseph G Rogers
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA
| | - Biykem Bozkurt
- Department of Medicine, Cardiology Section, Winters Center for Heart Failure Research, Cardiovascular Research Institute, Baylor College of Medicine, DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Sankar D Navaneethan
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA; Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Salim S Virani
- The Aga Khan University, Karachi, Pakistan; Michael E. DeBakey Veterans Affairs Medical Center, Texas Heart Institute, and Baylor College of Medicine, Houston, Texas.
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25
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De Belen E, Ganesan D, Paculdo D, Gill R, Peabody JW. Clinical Variation in the Treatment Practices for Patients With Type 2 Diabetes: A Cross-Sectional Patient Simulation Study Among Primary Care Physicians and Cardiologists. J Am Heart Assoc 2023; 12:e028634. [PMID: 37382120 PMCID: PMC10356086 DOI: 10.1161/jaha.122.028634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/07/2023] [Indexed: 06/30/2023]
Abstract
Background Cardiovascular disease risk stratification is necessary and critically important in patients with type 2 diabetes. Despite its known benefits to guide treatment and prevention, we hypothesized that providers do not routinely incorporate this into their diagnostic and treatment decisions. Methods and Results The QuiCER DM (QURE CVD Evaluation of Risk in Diabetes Mellitus) study enrolled 161 primary care physicians and 80 cardiologists. Between March 2022 and June 2022, we measured the care variation in risk determination among these providers caring for simulated patients with type 2 diabetes. We found a wide variation in the overall assessment of cardiovascular disease in patients with type 2 diabetes. Participants performed half of the necessary care items with quality-of-care scores, ranging between 13% and 84%, averaging 49.4±12.6%. Participants did not assess cardiovascular risk in 18.3% of cases and incorrectly stratified risk in 42.8% of cases. Only 38.9% of participants arrived at the correct cardiovascular risk stratification. Those who correctly identified a cardiovascular risk score were significantly more likely to order nonpharmacologic treatments, advising on their patients' nutrition (38.8% versus 29.9%, P=0.013) and the correct glycated hemoglobin target (37.7% versus 15.6%, P<0.001). Pharmacologic treatments, however, did not vary between those who correctly specified risk and those who did not. Conclusions Physician participants struggled to determine the correct cardiovascular disease risk and specify the appropriate pharmacologic interventions in simulated patients with type 2 diabetes. Additionally, there was a wide variation in the quality of care regardless of risk level, indicating opportunities to improve risk stratification.
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Affiliation(s)
| | | | | | | | - John W. Peabody
- QURE HealthcareSan FranciscoCAUSA
- University of CaliforniaSan FranciscoCAUSA
- University of CaliforniaLos AngelesCAUSA
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Gregg LP, Ramsey DJ, Akeroyd JM, Jafry SA, Matheny ME, Virani SS, Navaneethan SD. Predictors, Disparities, and Facility-Level Variation: SGLT2 Inhibitor Prescription Among US Veterans With CKD. Am J Kidney Dis 2023; 82:53-62.e1. [PMID: 36702340 PMCID: PMC10293070 DOI: 10.1053/j.ajkd.2022.11.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/27/2022] [Indexed: 01/25/2023]
Abstract
RATIONALE & OBJECTIVE Sodium/glucose cotransporter 2 (SGLT2) inhibitors are recommended for type 2 diabetes mellitus (T2DM) in patients with chronic kidney disease (CKD) or atherosclerotic cardiovascular disease (ASCVD). We evaluated factors associated with SGLT2 inhibitor prescription, disparities by race and sex, and facility-level variation in prescription patterns. STUDY DESIGN Retrospective cohort. SETTING & PARTICIPANTS A national sample of US veterans with comorbid T2DM, CKD, and ASCVD with a primary care visit between January 1 and December 31, 2020. EXPOSURE Race, sex, and individual Veterans Affairs (VA) location. OUTCOME SGLT2 inhibitor prescription. ANALYTICAL APPROACH Multivariable logistic regression assessed associations of race and sex with SGLT2 inhibitor prescription. Facility-level variation in SGLT2i prescription was quantified by median rate ratios (MRR), which express the likelihood that 2 randomly selected facilities differ in their use of SGLT2 inhibitor among similar patients. RESULTS Of 174,443 patients with CKD, T2DM, and ASCVD, 20,024 (11.5%) were prescribed an SGLT2 inhibitor. Lower odds of SGLT2 inhibitor prescription were seen in Black or African American patients compared with White patients (OR, 0.87 [95% CI, 0.83-0.91]) and among women compared with men (OR, 0.59 [95% CI 0.52-0.67]). The adjusted MRR for SGLT2 inhibitor prescription was 1.58 (95% CI 1.48-1.67) in the total cohort, indicating an unexplained 58% variation in treatment between VA facilities, independent of patient and facility characteristics. Facility-level variation was evaluated among Black or African American patients (MRR, 1.55 [95% CI 1.41-1.68]), White patients (MRR, 1.57 [95% CI 1.47-1.66]), women (MRR, 1.40 [95% CI 1.28-1.51]), and men (MRR, 1.57 [95% CI 1.48-1.67]). LIMITATIONS Albuminuria was not assessed. CONCLUSIONS Prescription for SGLT2 inhibitors was low among likely eligible patients, with evident disparities by sex and race and between individual VA facilities. Efforts are needed to study and address the reasons for these disparities to improve equitable adoption of these important medications.
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Affiliation(s)
- L Parker Gregg
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Nephrology Michael E. DeBakey Veterans Affairs Medical Center, and Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX; Michael E. DeBakey Veterans Affairs Medical Center, and Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - David J Ramsey
- Michael E. DeBakey Veterans Affairs Medical Center, and Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Julia M Akeroyd
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Michael E. DeBakey Veterans Affairs Medical Center, and Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Shehrezade A Jafry
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Michael E. DeBakey Veterans Affairs Medical Center, and Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Michael E Matheny
- Geriatrics Research Education and Clinical Care Service, Tennessee Valley Healthcare System VA, Nashville, Tennessee; Departments of Biomedical Informatics, Biostatistics, and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Salim S Virani
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Cardiology Michael E. DeBakey Veterans Affairs Medical Center, and Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX; Michael E. DeBakey Veterans Affairs Medical Center, and Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Sankar D Navaneethan
- Institute of Clinical and Translational Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Nephrology Michael E. DeBakey Veterans Affairs Medical Center, and Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX; Michael E. DeBakey Veterans Affairs Medical Center, and Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX.
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He D, Aleksic S. Is it time to repurpose geroprotective diabetes medications for prevention of dementia? J Am Geriatr Soc 2023; 71:2041-2045. [PMID: 37227136 PMCID: PMC10524156 DOI: 10.1111/jgs.18405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/10/2023] [Accepted: 04/15/2023] [Indexed: 05/26/2023]
Abstract
See related Editorial by Tang et al. in this issue.
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Affiliation(s)
- Diana He
- Department of Internal Medicine, Montefiore Medical Center, Bronx NY
| | - Sandra Aleksic
- Deaprtement of Internal Medicine, Divisions of Endocrinology and Geriatrics, Albert Einstein College of Medicine, Bronx NY
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Scheen AJ. Bridging the gap in cardiovascular care in diabetic patients: are cardioprotective antihyperglycemic agents underutilized? Expert Rev Clin Pharmacol 2023; 16:1053-1062. [PMID: 37919944 DOI: 10.1080/17512433.2023.2279193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/31/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Atherosclerotic cardiovascular disease (ASCVD) and heart failure (HF) are two major complications of type 2 diabetes (T2DM). Cardiovascular protection is a key objective, yet not fully reached in clinical practice. AREAS COVERED Both glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is) have proven their efficacy in reducing major cardiovascular events in high-risk patients with T2DM and SGLT2is in reducing hospitalization for HF in placebo-controlled randomized trials. However, real-life studies worldwide revealed that only a minority of patients with T2DM receive either a GLP-1RA or an SGLT2i and surprisingly even less patients with established ASCVD or HF are treated with these cardioprotective antihyperglycemic agents. EXPERT OPINION Bridging the gap between evidence-based cardiovascular protection with GLP-1RAs and SGLT2is and their underuse in daily clinical practice in patients with T2DM at high risk is crucial from a public health viewpoint. However, the task appears hazardous and the goal not attained considering the current failure. Education of specialists/primary care physicians and patients is critical. Multifaceted and coordinated interventions involving all actors (physicians, patients and broadly health-care system) must be implemented to stimulate the adoption of these cardioprotective antihyperglycemic medications as part of routine cardiovascular care among patients with T2DM.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium
- Division of Diabetes, Nutrition and Metabolic Disorders, CHU Liège, Liège, Belgium
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Pandey A, Khan MS, Patel KV, Bhatt DL, Verma S. Predicting and preventing heart failure in type 2 diabetes. Lancet Diabetes Endocrinol 2023:S2213-8587(23)00128-6. [PMID: 37385290 DOI: 10.1016/s2213-8587(23)00128-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 04/25/2023] [Accepted: 05/04/2023] [Indexed: 07/01/2023]
Abstract
The burden of heart failure among people with type 2 diabetes is increasing globally. People with comorbid type 2 diabetes and heart failure often have worse outcomes than those with only one of these conditions-eg, higher hospitalisation and mortality rates. Therefore, it is essential to implement optimal heart failure prevention strategies for people with type 2 diabetes. A detailed understanding of the pathophysiology underlying the occurrence of heart failure in type 2 diabetes can aid clinicians in identifying relevant risk factors and lead to early interventions that can help prevent heart failure. In this Review, we discuss the pathophysiology and risk factors of heart failure in type 2 diabetes. We also review the risk assessment tools for predicting heart failure incidence in people with type 2 diabetes as well as the data from clinical trials that have assessed the efficacy of lifestyle and pharmacological interventions. Finally, we discuss the potential challenges in implementing new management approaches and offer pragmatic recommendations to help overcome these challenges.
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Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Kershaw V Patel
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.
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30
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Scheen AJ. Underuse of glucose-lowering medications associated with cardiorenal protection in type 2 diabetes: from delayed initiation to untimely discontinuation. Lancet Reg Health Eur 2023; 29:100627. [PMID: 37025106 PMCID: PMC10070122 DOI: 10.1016/j.lanepe.2023.100627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/17/2023] [Indexed: 04/01/2023] Open
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Essien UR, Singh B, Swabe G, Johnson AE, Eberly LA, Wadhera RK, Breathett K, Vaduganathan M, Magnani JW. Association of Prescription Co-payment With Adherence to Glucagon-Like Peptide-1 Receptor Agonist and Sodium-Glucose Cotransporter-2 Inhibitor Therapies in Patients With Heart Failure and Diabetes. JAMA Netw Open 2023; 6:e2316290. [PMID: 37261826 PMCID: PMC10236237 DOI: 10.1001/jamanetworkopen.2023.16290] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/18/2023] [Indexed: 06/02/2023] Open
Abstract
Importance Type 2 diabetes (T2D) and heart failure (HF) prevalence are rising in the US. Although glucagon-like peptide-1 receptor agonists (GLP1-RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve outcomes for these conditions, high out-of-pocket costs may be associated with reduced medication adherence. Objective To compare 1-year adherence to GLP1-RA and SGLT2i therapies by prescription co-payment level in individuals with T2D and/or HF. Design, Setting, and Participants This retrospective cohort study used deidentified data from Optum Insight's Clinformatics Data Mart Database of enrollees with commercial and Medicare health insurance plans. Individuals aged 18 years or older with T2D and/or HF who had a prescription claim for a GLP1-RA or SLGT2i from January 1, 2014, to September 30, 2020, were included. Exposures Prescription co-payment, categorized as low (<$10), medium ($10 to<$50), and high (≥$50). Main Outcomes and Measures The primary outcome was medication adherence, defined as a proportion of days covered (PDC) of 80% or greater at 1 year. Logistic regression models were used to examine the association between co-payment and adherence, adjusting for patient demographics, medical comorbidities, and socioeconomic factors. Results A total of 94 610 individuals (mean [SD] age, 61.8 [11.4] years; 51 226 [54.1%] male) were prescribed GLP1-RA or SGLT2i therapy. Overall, 39 149 individuals had a claim for a GLP1-RA, of whom 25 557 (65.3%) had a PDC of 80% or greater at 1 year. In fully adjusted models, individuals with a medium (adjusted odds ratio [AOR], 0.62; 95% CI, 0.58-0.67) or high (AOR, 0.47; 95% CI, 0.44-0.51) co-payment were less likely to have a PDC of 80% or greater with a GLP1-RA compared with those with a low co-payment. Overall, 51 072 individuals had a claim for an SGLT2i, of whom 37 339 (73.1%) had a PDC of 80% or greater at 1 year. Individuals with a medium (AOR, 0.67; 95% CI, 0.63-0.72) or high (AOR, 0.68; 95% CI, 0.63-0.72) co-payment were less likely to have a PDC of 80% or greater with an SGLT2i compared with those with a low co-payment. Conclusions and Relevance In this cohort study of individuals with T2D and/or HF, 1-year adherence to GLP1-RA or SGLT2i therapies was highest among individuals with a low co-payment. Improving adherence to guideline-based therapies may require interventions that reduce out-of-pocket prescription costs.
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Affiliation(s)
- Utibe R. Essien
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Balvindar Singh
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gretchen Swabe
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amber E. Johnson
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lauren A. Eberly
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia
- Penn Cardiovascular Center for Health Equity and Social Justice, University of Pennsylvania, Philadelphia
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jared W. Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Research on Health Care, University of Pittsburgh Department of Medicine, Pittsburgh, Pennsylvania
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Khan MS, Segar MW, Usman MS, Patel KV, Van Spall HGC, DeVore AD, Vaduganathan M, Lam CSP, Zannad F, Verma S, Butler J, Tang WHW, Pandey A. Effect of Canagliflozin on Heart Failure Hospitalization in Diabetes According to Baseline Heart Failure Risk. JACC. HEART FAILURE 2023:S2213-1779(23)00186-5. [PMID: 37227388 DOI: 10.1016/j.jchf.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/20/2023] [Accepted: 03/27/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND In the CANVAS (Canagliflozin Cardiovascular Assessment Study) program, canagliflozin reduced the risk of heart failure (HF) hospitalization among individuals with type 2 diabetes mellitus (T2DM). OBJECTIVES The purpose of this study was to evaluate heterogeneity in absolute and relative treatment effects of canagliflozin on HF hospitalization according to baseline HF risk as assessed by diabetes-specific HF risk scores (WATCH-DM [Weight (body mass index), Age, hyperTension, Creatinine, HDL-C, Diabetes control (fasting plasma glucose) and QRS Duration, MI and CABG] and TRS-HFDM [TIMI Risk Score for HF in Diabetes]). METHODS Participants in the CANVAS trial were categorized into low, medium, and high risk for HF using the WATCH-DM score (for participants without prevalent HF) and the TRS-HFDM score (for all participants). The outcome of interest was time to first HF hospitalization. The treatment effect of canagliflozin vs placebo for HF hospitalization was compared across risk strata. RESULTS Among 10,137 participants with available HF data, 1,446 (14.3%) had HF at baseline. Among participants without baseline HF, WATCH-DM risk category did not modify the treatment effect of canagliflozin (vs placebo) on HF hospitalization (P interaction = 0.56). However, the absolute and relative risk reduction with canagliflozin was numerically greater in the high-risk group (cumulative incidence, canagliflozin vs placebo: 8.1% vs 12.7%; HR: 0.62 [95% CI: 0.37-0.93]; P = 0.03; number needed to treat: 22) than in the low- and intermediate-risk groups. When overall study participants were categorized according to the TRS-HFDM score, a statistically significant difference in the treatment effect of canagliflozin across risk strata was observed (P interaction = 0.04). Canagliflozin significantly reduced the risk of HF hospitalization by 39% in the high-risk group (HR: 0.61 [95% CI: 0.48-0.78]; P < 0.001; number needed to treat: 20) but not in the intermediate- or low-risk groups. CONCLUSIONS Among participants with T2DM, the WATCH-DM and TRS-HFDM can reliably identify those at high risk for HF hospitalization and most likely to benefit from canagliflozin.
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Affiliation(s)
- Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA
| | - Muhammad Shariq Usman
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Kershaw V Patel
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Harriette G C Van Spall
- Department of Medicine, Population Health Research Institute, Research Institute of St. Joseph's, McMaster University, Hamilton, Ontario, Canada
| | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore
| | - Faiez Zannad
- Université de Lorraine, CIC Insert, CHRU, Nancy, France
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Ontario, Canada
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Liew A, Lydia A, Matawaran BJ, Susantitaphong P, Tran HTB, Lim LL. Practical considerations for the use of SGLT-2 inhibitors in the Asia-Pacific countries-An expert consensus statement. Nephrology (Carlton) 2023. [PMID: 37153973 DOI: 10.1111/nep.14167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/10/2023]
Abstract
Recent clinical studies have demonstrated the effectiveness of SGLT-2 inhibitors in reducing the risks of cardiovascular and renal events in both patients with and without type 2 diabetes mellitus. Consequently, many international guidelines have begun advocating for the use of SGLT-2 inhibitors for the purpose of organ protection rather than as simply a glucose-lowering agent. However, despite the consistent clinical benefits and available strong guideline recommendations, the utilization of SGLT-2 inhibitors have been unexpectedly low in many countries, a trend which is much more noticeable in low resource settings. Unfamiliarity with the recent focus in their organ protective role and clinical indications; concerns with potential adverse effects of SGLT-2 inhibitors, including acute kidney injury, genitourinary infections, euglycemic ketoacidosis; and their safety profile in elderly populations have been identified as deterring factors to their more widespread use. This review serves as a practical guide to clinicians managing patients who could benefit from SGLT-2 inhibitors treatment and instill greater confidence in the initiation of these drugs, with the aim of optimizing their utilization rates in high-risk populations.
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Affiliation(s)
- Adrian Liew
- The Kidney & Transplant Practice, Mount Elizabeth Novena Hospital, Singapore, Singapore
| | - Aida Lydia
- Division of Nephrology and Hypertension, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia-Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Bien J Matawaran
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Santo Tomas Hospital, Manila, Philippines
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Huong Thi Bich Tran
- Renal Division, Department of Medicine, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Lee Ling Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China
- Asia Diabetes Foundation, Hong Kong, SAR, China
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Fang L, Li G, Ren J, Duan J, Dong J, Liu Z. Integrated analysis for treatment scheme of sodium-glucose cotransporter 2 inhibitors in patients with diabetic kidney disease: a real-world study. Sci Rep 2023; 13:5969. [PMID: 37045938 PMCID: PMC10097684 DOI: 10.1038/s41598-023-33211-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 04/09/2023] [Indexed: 04/14/2023] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are recommended for type 2 diabetes mellitus patients with impaired renal function, but the actual situation of SGLT2i using is unclear. Therefore, in this real-world study, we analyzed the treatment scheme and clinical characteristics of SGLT2i in patients with diabetic kidney disease (DKD). We included DKD patients hospitalized in the First Affiliated Hospital of Zhengzhou University from October 2017 to March 2020. The Apriori algorithm of association rules was used to analysis treatment scheme prescribing SGLT2i and other different combinations of hypoglycemic drugs. SGLT2i was used in 781 (12.3%) of 6336 DKD patients, both number and proportion of patients using SGLT2i increased from 2017 to 2020 (1.9% to 33%). Nighty-eight percent of all DKD patients using SGLT2i were combined with other glucose-lowering agents, and insulin, metformin and alpha-glucosidase inhibitors are most commonly used in combination with hypoglycemic drugs. Multivariate analysis showed that compared with non-SGLT2i group, patients using SGLT2i were associated with younger age, higher BMI, higher HbA1c, preserved kidney function, dyslipidemia and combined with ACEI/ARB and statins. In this real-world study, use of SGLT2i in DKD patients is still low. Most patients performed younger age and in the early stages of chronic kidney disease with poor glycemic control. Clinical inertia should be overcome to fully exert the cardiorenal protective effects of SGLT2 inhibitors, with attention to rational drug use.
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Affiliation(s)
- Li Fang
- Department of Integrated Traditional and Western Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China
- Henan Province Research Center for Kidney Disease, Zhengzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China
- Clinical Research Center of Big-Data, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guangpu Li
- Department of Integrated Traditional and Western Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China
- Henan Province Research Center for Kidney Disease, Zhengzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China
- Clinical Research Center of Big-Data, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingjing Ren
- Department of Integrated Traditional and Western Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China
- Henan Province Research Center for Kidney Disease, Zhengzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China
- Clinical Research Center of Big-Data, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiayu Duan
- Department of Integrated Traditional and Western Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China.
- Henan Province Research Center for Kidney Disease, Zhengzhou, China.
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China.
- Clinical Research Center of Big-Data, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Jiancheng Dong
- Clinical Research Center of Big-Data, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Zhangsuo Liu
- Department of Integrated Traditional and Western Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China.
- Henan Province Research Center for Kidney Disease, Zhengzhou, China.
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China.
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Tang S, Shao H, Ali MK, Zhang P. Recommended and Prevalent Use of Glucagon-like Peptide-1 Receptor Agonists and Sodium-Glucose Cotransporter-2 Inhibitors in a National Population-Based Sample. Ann Intern Med 2023; 176:582-583. [PMID: 36848654 PMCID: PMC10422868 DOI: 10.7326/m22-3051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Affiliation(s)
- Shichao Tang
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Hui Shao
- Department of Family and Preventive Medicine, School of Medicine, and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Mohammed K Ali
- Department of Family and Preventive Medicine, School of Medicine, and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ping Zhang
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Li Y, Hu H, Zheng Y, Donahoo WT, Guo Y, Xu J, Chen WH, Liu N, Shenkman EA, Bian J, Guo J. Impact of Contextual-Level Social Determinants of Health on Newer Antidiabetic Drug Adoption in Patients with Type 2 Diabetes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20054036. [PMID: 36901047 PMCID: PMC10001625 DOI: 10.3390/ijerph20054036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 05/14/2023]
Abstract
BACKGROUND We aimed to investigate the association between contextual-level social determinants of health (SDoH) and the use of novel antidiabetic drugs (ADD), including sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1a) for patients with type 2 diabetes (T2D), and whether the association varies across racial and ethnic groups. METHODS Using electronic health records from the OneFlorida+ network, we assembled a cohort of T2D patients who initiated a second-line ADD in 2015-2020. A set of 81 contextual-level SDoH documenting social and built environment were spatiotemporally linked to individuals based on their residential histories. We assessed the association between the contextual-level SDoH and initiation of SGTL2i/GLP1a and determined their effects across racial groups, adjusting for clinical factors. RESULTS Of 28,874 individuals, 61% were women, and the mean age was 58 (±15) years. Two contextual-level SDoH factors identified as significantly associated with SGLT2i/GLP1a use were neighborhood deprivation index (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.81-0.94) and the percent of vacant addresses in the neighborhood (OR 0.91, 95% CI 0.85-0.98). Patients living in such neighborhoods are less likely to be prescribed with newer ADD. There was no interaction between race-ethnicity and SDoH on the use of newer ADD. However, in the overall cohort, the non-Hispanic Black individuals were less likely to use newer ADD than the non-Hispanic White individuals (OR 0.82, 95% CI 0.76-0.88). CONCLUSION Using a data-driven approach, we identified the key contextual-level SDoH factors associated with not following evidence-based treatment of T2D. Further investigations are needed to examine the mechanisms underlying these associations.
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Affiliation(s)
- Yujia Li
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Hui Hu
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Yi Zheng
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - William Troy Donahoo
- Division of Endocrinology, Diabetes and Metabolism, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Yi Guo
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Jie Xu
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Wei-Han Chen
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Ning Liu
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Elisabeth A. Shenkman
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Jiang Bian
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Correspondence: ; Tel.: +1-352-273-6533
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Silva-Almodóvar A, Nahata MC. Telehealth Intervention to Improve Uptake of Evidence-Based Medications among Patients with Type 2 Diabetes and Heart Failure or Cardiovascular Disease. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3613. [PMID: 36834307 PMCID: PMC9964915 DOI: 10.3390/ijerph20043613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/06/2023] [Accepted: 02/13/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Sodium glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide 1 receptor (GLP-1) agonists are recommended for patients with type two diabetes (T2D) and atherosclerotic cardiovascular disease (ASCVD) or heart failure (HF) to reduce cardiovascular-related mortality. The objective of this study was to evaluate a telehealth targeted medication review (TMR) program to identify patients for uptake of these evidence-based medications. METHODS This was an observational descriptive study of a TMR program for Medicare-enrolled, Medication Therapy Management-eligible patients in one insurance plan. Prescription claims and patient interviews identified individuals who would benefit from SGLT-2 inhibitors or GLP-1 agonists. Facsimiles were sent to providers of patients with educational information about the targeted medications. Descriptive statistics described characteristics and proportion of patients prescribed targeted medications after 120 days. Bivariate statistical tests evaluated associations between age, sex, number of medications, number of providers, and poverty level with adoption of targeted medications. RESULTS A total of 1106 of 1127 had a facsimile sent to their provider after a conversation with the patient. Among patients with a provider facsimile, 69 (6%) patients filled a prescription for a targeted medication after 120 days. There was a significant difference in age between individuals who started a targeted medication (67 ± 10 years) compared with patients who did not (71 ± 10 years) (p = 0.001). CONCLUSIONS A TMR efficiently identified patients with T2D and ASCVD or HF who would benefit from evidence-based medications. Although younger patients were more likely to receive these medications, the overall uptake of these medications within four months of the intervention was lower than expected.
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Affiliation(s)
- Armando Silva-Almodóvar
- Institute of Therapeutic Innovations and Outcomes (ITIO), College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Milap C. Nahata
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
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Forman JL, Mercurio MG. Vulvar Pruritus in Postmenopausal Diabetic Women With Candidiasis Secondary to Sodium-Glucose Cotransporter Receptor-2 Inhibitors. J Low Genit Tract Dis 2023; 27:68-70. [PMID: 36129363 DOI: 10.1097/lgt.0000000000000704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Jessica L Forman
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY
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Cromer SJ, Lauffenburger JC, Levin R, Patorno E. Deficits and Disparities in Early Uptake of Glucagon-Like Peptide 1 Receptor Agonists and SGLT2i Among Medicare-Insured Adults Following a New Diagnosis of Cardiovascular Disease or Heart Failure. Diabetes Care 2023; 46:65-74. [PMID: 36383481 PMCID: PMC9797651 DOI: 10.2337/dc22-0383] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 10/09/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the association of race/ethnicity and socioeconomic deprivation with initiation of guideline-recommended diabetes medications with cardiovascular benefit (glucagon-like peptide 1 receptor agonists [GLP1-RA] and sodium-glucose cotransporter 2 inhibitors [SGLT2i]) among older adults with type 2 diabetes (T2D) and either incident atherosclerotic cardiovascular disease (ASCVD) or congestive heart failure (CHF). RESEARCH DESIGN AND METHODS Using Medicare data (2016-2019), we identified 4,057,725 individuals age >65 years with T2D and either incident ASCVD or CHF. We estimated incidence rates and hazard ratios (HR) of GLP1-RA or SGLT2i initiation within 180 days by race/ethnicity and zip code-level Social Deprivation Index (SDI) using adjusted Cox proportional hazards models. RESULTS Incidence rates of GLP1-RA or SGLT2i initiation increased over time but remained low (<0.6 initiations per 100 person-months) in all years studied. Medication initiation was less common among those of Black or other race/ethnicity (HR 0.81 [95% CI 0.79-0.84] and HR 0.84 [95% CI 0.75-0.95], respectively) and decreased with increasing SDI (HR 0.96 [95% CI 0.96-0.97]). Initiation was higher in ASCVD than CHF (0.35 vs. 0.135 initiations per 100 person-months). Moderate (e.g., nephropathy, nonalcoholic fatty liver disease) but not severe (e.g., advanced chronic kidney disease, cirrhosis) comorbidities were associated with higher probability of medication initiation. CONCLUSIONS Among older adults with T2D and either ASCVD or CHF, initiation of GLP1-RA or SGLT2i was low, suggesting a substantial deficit in delivery of guideline-recommended care or treatment barriers. Individuals of Black and other race/ethnicity and those with higher area-level socioeconomic deprivation were less likely to initiate these medications.
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Affiliation(s)
- Sara J. Cromer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Julie C. Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Muacevic A, Adler JR, Lopes AE, Lima Ferreira J, Príncipe RM. Underprescription of SGLT2i and GLP-1 RA: CAREPRO-T2D (Cardiorenal Protection in Type 2 Diabetes) Cross-Sectional Study. Cureus 2023; 15:e33509. [PMID: 36628395 PMCID: PMC9826698 DOI: 10.7759/cureus.33509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2023] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND New glucose-lowering drugs have shown benefits regarding cardiovascular events, heart failure, and kidney-related outcomes in type 2 diabetes (T2D). This study aimed to estimate the adequacy of SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP-1 RA) prescription to people living with T2D with established atherosclerotic cardiovascular disease (ASCVD) or heart failure (HF). MATERIAL AND METHODS This was a cross-sectional study based on adults with T2D in a Portuguese local health unit between January 2019 and January 2020. Subjects with ASCVD were compared with subjects without ASCVD, and subjects with HF were compared with subjects without HF regarding clinical and demographic characteristics. RESULTS Our study included 13,869 adults with T2D, among whom 5.9% were coded for HF and 20.4% were defined as having ASCVD. SGLT2i were prescribed to 36.0% of subjects with HF. SGLT2i and/or GLP-1 RA were prescribed to 36.1% of patients with ASCVD. When comparing with subjects without ASCVD, subjects with ASCVD were significantly older (70.8 vs. 66.5 years, p<0.001), had lower estimated glomerular filtration rate (68.2 vs. 74.6 mL/min/1.73 m2, p<0.001), and higher rates of prescription of SGLT2i and/or GLP-1 RA (36.1 vs. 31.4%, p<0.001). When comparing with subjects without HF, subjects with HF were significantly older (74.6 vs. 66.9 years, p<0.001), had lower estimated glomerular filtration rate (59.6 vs. 74.1, mL/min/1.73 m2, p<0.001), and higher rates of prescription of SGLT2i (36.0 vs. 30.3%, p<0.001). CONCLUSION SGLT2i and GLP-1 RA are underprescribed in T2D, with almost two-thirds of patients not being prescribed these agents despite being strongly advised by current guidelines. These findings highlight the need for specific actions to improve T2D management at primary care level.
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O'Keefe JH, O'Keefe EL, Nassif ME, Lavie CJ. Brave New World: Improving Obesity and Preventing Cardiovascular Disease. Mayo Clin Proc 2023; 98:11-14. [PMID: 36603940 DOI: 10.1016/j.mayocp.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/21/2022] [Indexed: 01/04/2023]
Affiliation(s)
- James H O'Keefe
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO.
| | | | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA
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Chawla K, Furlong R, Kamo N, Gerbino I, Smith D, Blackmore C. Clinical spotlight intervention to accelerate translation of evidence-based practices in primary care. BMJ Open Qual 2022; 11:bmjoq-2022-002032. [PMID: 36581350 PMCID: PMC9806053 DOI: 10.1136/bmjoq-2022-002032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 12/14/2022] [Indexed: 12/30/2022] Open
Abstract
Evidence-based medical practice is often slow to diffuse into widespread clinical practice. To accelerate translation of updated best practices into clinical care, we developed a quality improvement intervention called the 'Clinical Spotlight'. This programme was based on a knowledge translation model of four steps: education on evidence-based practices, using Lean for incorporation into patient care flow, support of implementation and sustainability, and measurement of outcomes. Using the Clinical Spotlight intervention for addressing the care of patients with type 2 diabetes was associated with appropriate increases in the use of newer classes of glycaemic control medications. We demonstrate statistically significant increases in the use of promoted glycaemic control agents (sodium-glucose cotransporter-2 inhibitor and glucagon-like peptide-1 receptor agonist classes of drugs) at the time of intervention. We conclude that translation of evidence-based practices into clinical care can be enhanced through an educational intervention linked to Lean process improvement and with supported implementation. We are currently expanding our programme to additional clinical areas in primary care.
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Affiliation(s)
- Kavita Chawla
- Primary Care, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Richard Furlong
- Primary Care, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Norris Kamo
- Primary Care, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Ingrid Gerbino
- Primary Care, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Donna Smith
- Primary Care, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Craig Blackmore
- Center for Health Care Improvement Science, Virginia Mason Franciscan Health, Tacoma, Washington, USA,Department of Radiology, University of Washington, Seattle, Washington, USA
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Nair R, Mody R, Yu M, Cowburn S, Konig M, Prewitt T. Real-World Treatment Patterns of Glucose-Lowering Agents Among Patients with Type 2 Diabetes Mellitus and Cardiovascular Disease or At Risk for Cardiovascular Disease: An Observational, Cross-Sectional, Retrospective Study. Diabetes Ther 2022; 13:1921-1932. [PMID: 36131064 PMCID: PMC9663782 DOI: 10.1007/s13300-022-01320-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/31/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION There is limited published literature on longitudinal utilization of glucose-lowering agents (GLAs) among patients with type 2 diabetes (T2D) and cardiovascular disease (CVD or risk of CVD). This retrospective, observational study aimed to provide updated evidence on patient characteristics and utilization of GLAs among patients with T2D and CVD or risk of CVD in the United States. METHODS This was a cross-sectional evaluation of patients with T2D aged 50-89 years with annual continuous enrolment in a Medicare Advantage and Prescription Drug plan, identified from administrative claims data (Humana Research Database). Patients with T2D and atherosclerotic cardiovascular disease (ASCVD) or heart failure (HF) (CVD cohort), or T2D and an additional CVD risk factor without pre-existing CVD (CVD risk cohort) were identified from 2015 to 2019. Patients were followed from their first observed ASCVD/HF diagnosis or CVD risk factor for each year they were continuously enrolled or until occurrence of a CVD diagnosis (CVD risk cohort only). Use of GLA classes were reported by year, cohort, and age groups (50-64 years and ≥ 65 years). RESULTS The percentage of patients on sodium-glucose co-transporter-2 inhibitors (SGLT-2is), glucagon-like peptide-1 receptor agonists (GLP-1 RAs), and GLP-1 RAs with proven cardiovascular benefit, respectively, increased from 2015 to 2019 among ≥ 65 years (CVD cohort: 1.1-3.4%, 1.6-4.0%, and 1.2-3.8%; CVD risk cohort: 1.4-3.7%, 2.0-4.3%, and 1.5-4.1%); and among 50-64 years (CVD cohort: 2.6-7.3%, 4.3-10.1%, and 3.4-9.4%; CVD risk cohort: 3.3-6.8%, 4.6-9.6%, and 3.5-8.9%). CONCLUSIONS Although use of SGLT-2is and GLP-1 RAs increased over time, overall utilization of these agents in patients with T2D and ASCVD/HF or at risk for ASCVD/HF remained low, especially for those aged ≥ 65 years.
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Affiliation(s)
- Radhika Nair
- Humana Healthcare Research, Inc., Louisville, KY, USA
| | - Reema Mody
- Eli Lilly and Company, Indianapolis, IN, USA.
| | - Maria Yu
- Eli Lilly and Company, Indianapolis, IN, USA
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Lamprea-Montealegre JA, Madden E, Tummalapalli SL, Chu CD, Peralta CA, Du Y, Singh R, Kong SX, Tuot DS, Shlipak MG, Estrella MM. Prescription Patterns of Cardiovascular- and Kidney-Protective Therapies Among Patients With Type 2 Diabetes and Chronic Kidney Disease. Diabetes Care 2022; 45:2900-2906. [PMID: 36156061 PMCID: PMC9998844 DOI: 10.2337/dc22-0614] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 08/29/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the prevalence and correlates of prescription of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and/or glucagon-like peptide 1 receptor agonists (GLP1-RA) in individuals with type 2 diabetes mellitus (T2DM) with and without chronic kidney disease (CKD). RESEARCH DESIGN AND METHODS This was a cross-sectional analyses of SGLT2i and GLP1-RA prescriptions from 1 January 2019 to 31 December 2020 in the Veterans Health Administration System. The likelihood of prescriptions was examined by the presence or absence of CKD and by predicted risks of atherosclerotic cardiovascular disease (ASCVD) and end-stage kidney disease (ESKD). RESULTS Of 1,197,880 adults with T2DM, SGLT2i and GLP1-RA were prescribed to 11% and 8% of patients overall, and to 12% and 10% of those with concomitant CKD, respectively. In adjusted models, patients with severe albuminuria were less likely to be prescribed SGLT2i or GLP1-RA versus nonalbuminuric patients with CKD, with odds ratios (ORs) of 0.91 (95% CI 0.89, 0.93) and 0.97 (0.94, 1.00), respectively. Patients with a 10-year ASCVD risk >20% (vs. <5%), had lower odds of SGLT2i use (OR 0.66 [0.61, 0.71]) and GLP1-RA prescription (OR 0.55 [0.52, 0.59]). A 5-year ESKD risk >5%, compared with <1%, was associated with lower likelihood of SGLT2i prescription (OR 0.63 [0.59, 0.67]) but higher likelihood of GLP1-RA prescription (OR 1.53 [1.46, 1.61]). CONCLUSIONS Among a large cohort of patients with T2DM, prescription of SGLT2i and GLP1-RA was low in those with CKD. We observed a "risk-treatment paradox," whereby patients with higher risk of adverse outcomes were less likely to receive these therapies.
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Affiliation(s)
- Julio A. Lamprea-Montealegre
- Department of Medicine, University of California, San Francisco, San Francisco, CA
- Kidney Health Research Collaborative, University of California, San Francisco, San Francisco, CA
- San Francisco Veterans Administration Health Care System, San Francisco, CA
| | - Erin Madden
- Kidney Health Research Collaborative, University of California, San Francisco, San Francisco, CA
- San Francisco Veterans Administration Health Care System, San Francisco, CA
| | - Sri Lekha Tummalapalli
- Kidney Health Research Collaborative, University of California, San Francisco, San Francisco, CA
- San Francisco Veterans Administration Health Care System, San Francisco, CA
- Division of Healthcare Delivery Science & Innovation, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Chi D. Chu
- Department of Medicine, University of California, San Francisco, San Francisco, CA
- Kidney Health Research Collaborative, University of California, San Francisco, San Francisco, CA
| | - Carmen A. Peralta
- Department of Medicine, University of California, San Francisco, San Francisco, CA
- Kidney Health Research Collaborative, University of California, San Francisco, San Francisco, CA
- Cricket Health, Inc., San Francisco, CA
| | - Yuxian Du
- Bayer Healthcare U.S. LLC, Whippany, NJ
| | | | | | - Delphine S. Tuot
- Department of Medicine, University of California, San Francisco, San Francisco, CA
- Kidney Health Research Collaborative, University of California, San Francisco, San Francisco, CA
| | - Michael G. Shlipak
- Department of Medicine, University of California, San Francisco, San Francisco, CA
- Kidney Health Research Collaborative, University of California, San Francisco, San Francisco, CA
- San Francisco Veterans Administration Health Care System, San Francisco, CA
| | - Michelle M. Estrella
- Department of Medicine, University of California, San Francisco, San Francisco, CA
- Kidney Health Research Collaborative, University of California, San Francisco, San Francisco, CA
- San Francisco Veterans Administration Health Care System, San Francisco, CA
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Lyu B, Sang Y, Selvin E, Chang AR, Alexander GC, Cohen CM, Coresh J, Shalev V, Chodick G, Karasik A, Carrero JJ, Fu EL, Xu Y, Grams ME, Shin JI. Pharmacologic Treatment of Type 2 Diabetes in the U.S., Sweden, and Israel. Diabetes Care 2022; 45:2926-2934. [PMID: 36282149 PMCID: PMC9763031 DOI: 10.2337/dc22-1253] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 09/13/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To characterize and compare glucose-lowering medication use in type 2 diabetes in the U.S., Sweden, and Israel, including adoption of newer medications and prescribing patterns. RESEARCH DESIGN AND METHODS We used data from the National Health and Nutrition Examination Survey (NHANES) from the U.S., the Stockholm CREAtinine Measurements (SCREAM) project from Sweden, and Maccabi Healthcare Services (Maccabi) from Israel. Specific pharmacotherapy for type 2 diabetes between 2007 and 2018 was examined. RESULTS Use of glucose-lowering medications among patients with type 2 diabetes was substantially lower in NHANES and SCREAM than in Maccabi (66.0% in NHANES, 68.4% in SCREAM, and 88.1% in Maccabi in 2017-2018). Among patients who took at least one glucose-lowering medication in 2017-2018, metformin use was also lower in NHANES and SCREAM (74.1% in NHANES, 75.9% in SCREAM, and 92.6% in Maccabi) whereas sulfonylureas use was greater in NHANES (31.5% in NHANES, 16.0% in SCREAM, and 14.9% in Maccabi). Adoption of dipeptidyl peptidase 4 inhibitors and sodium-glucose cotransporter 2 inhibitors (SGLT2i) was slower in NHANES and SCREAM than in Maccabi. History of atherosclerotic cardiovascular disease, heart failure, reduced kidney function, or albuminuria was not consistently associated with greater use of SGLT2i or glucagon-like peptide 1 receptor agonists (GLP1RA) across the three countries. CONCLUSIONS There were substantial differences in real-world use of glucose-lowering medications across the U.S., Sweden, and Israel, with more optimal pharmacologic management in Israel. Variation in access to care and medication cost across countries may have contributed to these differences. SGLT2i and GLP1RA use in patients at high risk was limited in all three countries during this time period.
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Affiliation(s)
- Beini Lyu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Alex R. Chang
- Geisinger Kidney Health Research Institute, Danville, PA
| | - G. Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Cheli Melzer Cohen
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Varda Shalev
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Chodick
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avraham Karasik
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Endocrinology, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Edouard L. Fu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Yang Xu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Precision Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Tonelli M, Straus S. Increasing Societal Benefit From Cardiovascular Drugs. Circulation 2022; 146:1627-1635. [PMID: 36409780 DOI: 10.1161/circulationaha.122.059032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
During the past few years, several innovative treatments for noncommunicable chronic disease have become available, including SGLT2i (sodium-glucose cotransporter-2 inhibitors), GLP-1a (glucagon-like-peptide 1 agonists), ARNI (angiotensin receptor-neprilysin inhibitors), and finerenone, a selective nonsteroidal mineralocorticoid receptor antagonist. Each of these medications improves clinically relevant outcomes when added to existing therapies, and the indications for their use are rapidly expanding. Because existing drug regimens are already complex and costly, ensuring that society derives the maximal benefit from these new agents represents a major challenge. This Primer discusses how society can meet this challenge, which we address in terms of 5 principles: maximizing benefit, minimizing harm, optimizing uptake, increasing value for money, and ensuring equitable access. The Primer is most relevant for stakeholders in high-income countries, but the principles are broadly applicable to stakeholders in other settings, including low- and middle-income countries. We have focused the discussion on SGLT-2i, but the 5 principles herein could be used with reference to ARNI, finerenone, or any other health product.
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Affiliation(s)
| | - Sharon Straus
- Department of Medicine, University of Toronto, Canada (S.S.)
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Korayem GB, Alshaya OA, Alghamdi AA, Alanazi SS, Almutib RT, Alsaileek M, Alrashidi A, Aldosari N, Bin Sheraim N, Al Yami MS, Almohammed OA. The prescribing pattern of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists in patient with type two diabetes mellitus: A two-center retrospective cross-sectional study. Front Public Health 2022; 10:1031306. [PMID: 36408008 PMCID: PMC9673169 DOI: 10.3389/fpubh.2022.1031306] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/11/2022] [Indexed: 01/29/2023] Open
Abstract
Background The use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) in patients with type 2 diabetes mellitus (T2DM) remains limited, especially in those with other compelling indications. Thus, this study aimed to describe the prescribing patterns of GLP-1-RA and SGLT2i in patients with T2DM and to determine the factors that affect the prescribing of these medications. Methods This multicenter retrospective cross-sectional study reviewed the electronic health records of adult patients diagnosed with T2DM who received care between January and December 2020. The patients were classified according to their compelling indications into "patients who are more likely" to benefit from SGLT2i or GLP-1 RA and "patients who are less likely" to benefit from them. They were then further categorized depending on whether these medications were prescribed. Results A total of 1,220 patients were included; most were female (56.9%). SGLT2i or GLP-1 RA were preferably prescribed in only 19% of the patients for reasons including BMI ≥ 27 kg/m2 (85.6%), uncontrolled T2DM (68.5%), high risk for ASCVD (23.9%), or established ASCVD (14%). The remaining 81.0% were underprescribed these agents. Patients at an older age or with a history of stroke or transient ischemic attack had higher odds of being underprescribed (OR 1.02; 95% CI: 1.01-1.03 and OR 2.86; 95% CI: 1.33-6.15), respectively. Conclusion The results concur with those of previous studies highlighting the underutilization of GLP-1 RA and SGLT2i in patients with T2DM but also with compelling indications. To optimize the use of GLP-1 RA and SGLT2i for their additional benefits, prescribers need to assess the benefits of using these agents in patients who would likely benefit from them, regardless of DM control.
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Affiliation(s)
- Ghazwa B. Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia,*Correspondence: Ghazwa B. Korayem
| | - Omar A. Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Albandari A. Alghamdi
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Shahad S. Alanazi
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Renad T. Almutib
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Mahdi Alsaileek
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulrahman Alrashidi
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nasser Aldosari
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nader Bin Sheraim
- Pharmaceutical Care Services, King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Majed S. Al Yami
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Omar A. Almohammed
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia,Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Tye SC, Jongs N, Coca SG, Sundström J, Arnott C, Neal B, Perkovic V, Mahaffey KW, Vart P, Heerspink HJL. Initiation of the SGLT2 inhibitor canagliflozin to prevent kidney and heart failure outcomes guided by HbA1c, albuminuria, and predicted risk of kidney failure. Cardiovasc Diabetol 2022; 21:194. [PMID: 36151557 PMCID: PMC9508745 DOI: 10.1186/s12933-022-01619-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sodium glucose co-transporter-2 (SGLT2) inhibitors reduce the risk of kidney and heart failure events independent of glycemic effects. We assessed whether initiation of the SGLT2 inhibitor canagliflozin guided by multivariable predicted risk based on clinical characteristics and novel biomarkers is more efficient to prevent clinical outcomes compared to a strategy guided by HbA1c or urinary-albumin-creatinine ratio (UACR) alone. METHODS We performed a post-hoc analysis of the CANVAS trial including 3713 patients with available biomarker measurements. We compared the number of composite kidney (defined as a sustained 40% decline in eGFR, chronic dialysis, kidney transplantation, or kidney death) and composite heart failure outcomes (defined as heart failure hospitalization or cardiovascular (CV) death) prevented per 1000 patients treated for 5 years when canagliflozin was initiated in patients according to HbA1c ≥ 7.5%, UACR, or multivariable risk models consisting of: (1) clinical characteristics, or (2) clinical characteristics and novel biomarkers. Differences in the rates of events prevented between strategies were tested by Chi2-statistic. RESULTS After a median follow-up of 6.1 years, 144 kidney events were recorded. The final clinical model included age, previous history of CV disease, systolic blood pressure, UACR, hemoglobin, body weight, albumin, estimated glomerular filtration rate, and randomized treatment assignment. The combined biomarkers model included all clinical characteristics, tumor necrosis factor receptor-1, kidney injury molecule-1, matrix metallopeptidase-7 and interleukin-6. Treating all patients with HbA1c ≥ 7.5% (n = 2809) would prevent 33.0 (95% CI 18.8 to 43.3 ) kidney events at a rate of 9.6 (95% CI 5.5 to 12.6) events prevented per 1000 patients treated for 5 years. The corresponding rates were 5.8 (95% CI 3.4 to 7.9), 16.6 (95% CI 9.5 to 22.0) (P < 0.001 versus HbA1c or UACR approach), and 17.5 (95% CI 10.0 to 23.0) (P < 0.001 versus HbA1c or UACR approach; P = 0.54 versus clinical model). Findings were similar for the heart failure outcome. CONCLUSION Initiation of canagliflozin based on an estimated risk-based approach prevented more kidney and heart failure outcomes compared to a strategy based on HbA1c or UACR alone. There was no apparent gain from adding novel biomarkers to the clinical risk model. These findings support the use of risk-based assessment using clinical markers to guide initiation of SGLT2 inhibitors in patients with type 2 diabetes.
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Affiliation(s)
- Sok Cin Tye
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Steven G Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands. .,The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia.
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Lamprea-Montealegre JA, Madden E, Tummalapalli SL, Peralta C, Neilands TB, Garcia PK, Muiru A, Karliner L, Shlipak MG, Estrella MM. Association of Race and Ethnicity With Prescription of SGLT2 Inhibitors and GLP1 Receptor Agonists Among Patients With Type 2 Diabetes in the Veterans Health Administration System. JAMA 2022; 328:861-871. [PMID: 36066519 PMCID: PMC9449794 DOI: 10.1001/jama.2022.13885] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Novel therapies for type 2 diabetes can reduce the risk of cardiovascular disease and chronic kidney disease progression. The equitability of these agents' prescription across racial and ethnic groups has not been well-evaluated. OBJECTIVE To investigate differences in the prescription of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) among adult patients with type 2 diabetes by racial and ethnic groups. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis of data from the US Veterans Health Administration's Corporate Data Warehouse. The sample included adult patients with type 2 diabetes and at least 2 primary care clinic visits from January 1, 2019, to December 31, 2020. EXPOSURES Self-identified race and self-identified ethnicity. MAIN OUTCOMES AND MEASURES The primary outcomes were prevalent SGLT2i or GLP-1 RA prescription, defined as any active prescription during the study period. RESULTS Among 1 197 914 patients (mean age, 68 years; 96% men; 1% American Indian or Alaska Native, 2% Asian, Native Hawaiian, or Other Pacific Islander, 20% Black or African American, 71% White, and 7% of Hispanic or Latino ethnicity), 10.7% and 7.7% were prescribed an SGLT2i or a GLP-1 RA, respectively. Prescription rates for SGLT2i and GLP-1 RA, respectively, were 11% and 8.4% among American Indian or Alaska Native patients; 11.8% and 8% among Asian, Native Hawaiian, or Other Pacific Islander patients; 8.8% and 6.1% among Black or African American patients; and 11.3% and 8.2% among White patients, respectively. Prescription rates for SGLT2i and GLP-1 RA, respectively, were 11% and 7.1% among Hispanic or Latino patients and 10.7% and 7.8% among non-Hispanic or Latino patients. After accounting for patient- and system-level factors, all racial groups had significantly lower odds of SGLT2i and GLP-1 RA prescription compared with White patients. Black patients had the lowest odds of prescription compared with White patients (adjusted odds ratio, 0.72 [95% CI, 0.71-0.74] for SGLT2i and 0.64 [95% CI, 0.63-0.66] for GLP-1 RA). Patients of Hispanic or Latino ethnicity had significantly lower odds of prescription (0.90 [95% CI, 0.88-0.93] for SGLT2i and 0.88 [95% CI, 0.85-0.91] for GLP-1 RA) compared with non-Hispanic or Latino patients. CONCLUSIONS AND RELEVANCE Among patients with type 2 diabetes in the Veterans Health Administration system during 2019 and 2020, prescription rates of SGLT2i and GLP-1 RA medications were low, and individuals of several different racial groups and those of Hispanic ethnicity had statistically significantly lower odds of receiving prescriptions for these medications compared with individuals of White race and non-Hispanic ethnicity. Further research is needed to understand the mechanisms underlying these differences in rates of prescribing and the potential relationship with differences in clinical outcomes.
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Affiliation(s)
- Julio A. Lamprea-Montealegre
- Department of Medicine, University of California, San Francisco
- Kidney Health Research Collaborative, University of California, San Francisco
- San Francisco VA Health Care System, San Francisco, California
| | - Erin Madden
- Kidney Health Research Collaborative, University of California, San Francisco
- San Francisco VA Health Care System, San Francisco, California
| | - Sri Lekha Tummalapalli
- Kidney Health Research Collaborative, University of California, San Francisco
- Division of Healthcare Delivery Science & Innovation, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Carmen Peralta
- Department of Medicine, University of California, San Francisco
- Kidney Health Research Collaborative, University of California, San Francisco
- San Francisco VA Health Care System, San Francisco, California
- Cricket Health Inc, San Francisco, California
| | - Torsten B. Neilands
- Department of Medicine, University of California, San Francisco
- San Francisco Center for Aging in Diverse Communities and the Multiethnic Health Equity Research Center, University of California, San Francisco
| | - Paola K. Garcia
- Division of Nephrology, Department of Medicine, Pontificia Universidad Javeriana School of Medicine, Bogotá, Colombia
| | - Anthony Muiru
- Department of Medicine, University of California, San Francisco
- Kidney Health Research Collaborative, University of California, San Francisco
| | - Leah Karliner
- Department of Medicine, University of California, San Francisco
- San Francisco Center for Aging in Diverse Communities and the Multiethnic Health Equity Research Center, University of California, San Francisco
| | - Michael G. Shlipak
- Department of Medicine, University of California, San Francisco
- Kidney Health Research Collaborative, University of California, San Francisco
- San Francisco VA Health Care System, San Francisco, California
| | - Michelle M. Estrella
- Department of Medicine, University of California, San Francisco
- Kidney Health Research Collaborative, University of California, San Francisco
- San Francisco VA Health Care System, San Francisco, California
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50
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Hanna J, Nargesi AA, Essien UR, Sangha V, Lin Z, Krumholz HM, Khera R. County-level variation in cardioprotective antihyperglycemic prescribing among medicare beneficiaries. Am J Prev Cardiol 2022; 11:100370. [PMID: 35968531 PMCID: PMC9364091 DOI: 10.1016/j.ajpc.2022.100370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/29/2022] [Accepted: 07/31/2022] [Indexed: 12/01/2022] Open
Abstract
Background Cardioprotective antihyperglycemic agents, SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP1RA), improve outcomes of patients with type 2 diabetes, but adoption has been limited. Differences across individuals have been noted but area-level variation is unknown. Objectives Given healthcare access and sociodemographic differences, we evaluated whether SGLT2i and GLP-1RA utilization varies across US counties. Methods We linked 2019 Medicare Part D national prescription data with county-level demographic measures from the Agency for Health Quality and Research. We compared the number of beneficiaries receiving prescriptions for any cardioprotective antihyperglycemic to the number receiving metformin prescriptions across US counties. In multivariable linear regression with SGLT2i-to-metformin and GLP1RA-to-metformin prescriptions as outcomes, we evaluated county factors associated with use of cardioprotective agents while adjusting for sociodemographic measures, region, and cardiometabolic risk factor prevalence. Results In 3066 US counties, there were a median 2,416 (IQR, 1681-3190) metformin-receiving beneficiaries per 100,000 population. A median 6.2% of beneficiaries receiving metformin received SGLT2i therapy, varying across counties (IQR, 3.4%-9.2%). A median 9.4% (IQR, 5.0%-13.0%) of beneficiaries receiving metformin received GLP-1RA. In adjusted analyses, higher percentage of Black population was associated with lower use at the county level of people on SGLT2i or GLP-1RA relative to metformin (a SD higher proportion of Black individuals with 0.4% [95% CI, -0.6% to -0.1%] and 0.5% [-0.8% to -0.2%] lower SGLT2i and GLP-1RA prescribing relative to metformin, respectively; P < 0.01). A higher median age of county residents, rural location, and lower prevalence of diabetes were associated with lower SGLT2i prescribing. Similarly, more advanced age of county residents, rural location, proportion of Hispanic individuals, and household income and lower education levels were associated with lower GLP-1RA prescribing. Prescribing was higher in the Northeast and lower in the West as compared with the Midwest for both classes. Conclusion There was large variation by county in cardioprotective antihyperglycemic prescribing, with a pattern of lower use in Black-predominant and rural counties, highlighting the critical need to investigate equity in uptake of novel therapeutic agents.
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Affiliation(s)
- Jonathan Hanna
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Arash A Nargesi
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Utibe R. Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Veer Sangha
- Department of Computer Science, Yale University, New Haven, CT, USA
| | - Zhenqiu Lin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 195 Church St, 6th Floor, New Haven, CT 06510, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 195 Church St, 6th Floor, New Haven, CT 06510, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 195 Church St, 6th Floor, New Haven, CT 06510, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Corresponding author at: Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 195 Church St, 6th Floor, New Haven, CT 06510, USA.
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