Spotlight on prescribing patterns

One study found that physicians were unlikely to deprescribe hypoglycemia-causing medications in older diabetes patients, while others found suboptimal use of glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors, and additional recommended medications.

Several recent studies compared real-world prescribing of medication to patients with diabetes to guideline-recommended care.

A national survey, published by Diabetes Care on Feb. 17, looked at use of hypoglycemia-causing medications in older adults with diabetes. A total of 445 physicians in general medicine, geriatrics, or endocrinology (response rate, 37.5%) responded to three scenarios about patients taking hypoglycemia-causing medications: a 79-year-old in good health with an HbA1c level of 6.3% on a sulfonylurea, a 77-year-old in complex health with an HbA1c level of 7.3% on glargine insulin, and a 78-year-old in poor health with an HbA1c level of 7.7% on a sulfonylurea. Medications were deintensified by 48%, 4%, and 20% of respondents to the scenarios, respectively. Medication switching was suggested in only 17% of responses, and half of the physicians selected HbA1c targets below those recommended for older adults with complex or poor health. The study didn't determine why physicians targeted lower HbA1c levels than recommended, but training may have had an effect, the study authors said, “given our findings that geriatricians were more likely to deintensify medications than other specialties and that endocrinologists were more likely to switch.” They also noted that the low rates of switching medications may be related to concerns about insurance coverage.

Use of glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter-2 (SGLT-2) inhibitors was analyzed by a brief research report published by Annals of Internal Medicine on Feb. 28. Researchers used data from the National Health and Nutrition Examination Survey during 2017 to 2020 comprising 1,330 adults with self-reported type 2 diabetes. Based on guidelines released in 2022 by the American Diabetes Association and European Association for the Study of Diabetes, the two studied medication classes would be recommended for 82.3% of type 2 diabetes patients. In the study population, only 3.7% took GLP-1 receptor agonists, 5.3% took SGLT-2 inhibitors, and 9.1% took either drug class. “However, at current drug pricing, using these 2 new medications as first-line agents among all eligible patients with [type 2 diabetes] may not be cost-effective,” the study authors said. The authors noted their data predate the guidelines used for comparison, and they speculated that use of these medications might have increased since 2020. “Cost-effectiveness was not formally considered in the current guideline, but an assessment of cost-effectiveness may assist better targeting of interventions to achieve the greatest effect at a sustainable cost,” they said.

An industry-funded study, published by Diabetes, Obesity and Metabolism on Feb. 27, looked at use of four types of recommended medications in patients with cardiovascular disease (CVD), diabetes, and an LDL cholesterol level of 70 mg/dL or above. The study, conducted at 107 U.S. sites from 2016 to 2018, considered optimal medical therapy to entail a high-intensity statin, any statin plus ezetimibe, or a PCSK9 inhibitor; an antiplatelet or anticoagulant; an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB); and an SGLT-2 inhibitor and/or GLP-1 receptor agonist. After two years of follow-up, 11% of patients were on all four types of treatment (compared to 8% at baseline), with 58% on high-intensity lipid-lowering therapy, 87% on antithrombotic therapy, 71% on blood pressure treatment, and 17% on an SGLT-2 inhibitor/GLP-1 receptor agonist. In a hierarchical multivariable model, older age was associated with lower odds of receiving optimal therapy, and private insurance and coronary artery disease were associated with higher odds. The results indicate that many of these medication classes are underused, possibly due to socioeconomic factors, the study authors said. “While these associations are not unexpected in the case of SGLT-2 [inhibitors] and GLP-1 [receptor agonists], all other aspects of [optimal medical therapy] can be achieved with the use of inexpensive generic medications,” they noted.

Finally, an industry-funded intervention trial, published by JAMA on March 6, assessed an effort to optimize prescribing of three groups of recommended therapies (high-intensity statins, ACE inhibitors or ARBs, and SGLT-2 inhibitors and/or GLP-1 receptor agonists) to patients with diabetes and CVD. It was conducted at 43 U.S. cardiology clinics in 2019 to 2022 among 1,049 participants (459 at 20 intervention clinics and 590 at 23 usual care clinics) and entailed assessing local barriers, developing care pathways, coordinating care, educating clinicians, reporting data back to the clinics, and providing tools. At one year, all three therapies were prescribed to 37.9% of intervention patients versus 14.5% of control patients (adjusted odds ratio, 4.38; P<0.001). The individual medication categories were also prescribed at significantly higher rates to the intervention patients. However, the intervention was not associated with any change in CVD risk factors or any significant difference in the composite secondary outcome of all-cause death or hospitalization for myocardial infarction, stroke, decompensated heart failure, or urgent revascularization (5% vs. 6.8%; adjusted hazard ratio, 0.79 [95% CI, 0.46 to 1.33]). The results show that “while clinician behavior has historically proven difficult to change, an intervention with multiple synergistic components can have an effect on clinician prescribing patterns for evidence-based therapies,” said the study authors.