Trends in First-Line Glucose-Lowering Drug Use in Adults With Type 2 Diabetes in Light of Emerging Evidence for SGLT-2i and GLP-1RA

Abstract

Objective: We evaluated recent use trends and predictors of first-line antidiabetes treatment in patients with type 2 diabetes.

Research design and methods: Using two large U.S. health insurance databases (Clinformatics and Medicare), we identified adult patients with type 2 diabetes who initiated antidiabetes treatment from 2013 through 2019. Quarterly trends in use of first-line antidiabetes treatment were plotted overall and stratified by cardiovascular disease (CVD). Multinomial logistic regressions were fit to estimate predictors of first-line antidiabetes treatment, using metformin, the recommended first-line treatment for type 2 diabetes, as the common referent.

Results: Metformin was the most frequently initiated medication, used by 80.6% of Medicare beneficiaries and 83.1% of commercially insured patients. Sulfonylureas were used by 8.7% (Medicare) and 4.7% (commercial). Both populations had low use of sodium-glucose cotransporter 2 inhibitors (SGLT-2i, 0.8% [Medicare] and 1.7% [commercial]) and glucagon-like peptide 1 receptor agonists (GLP-1Ra; 1.0% [Medicare] and 3.5% [commercial]), with increasing trends over time (P < 0.01). Initiators of antidiabetes drugs with established cardiovascular benefits (SGLT-2i and GLP-1RA) were more likely to be younger and had prevalent CVD or higher socioeconomic status compared with initiators of metformin.

Conclusions: Among adult patients with type 2 diabetes, metformin was by far the most frequent first-line treatment. While the use of SGLT-2i and GLP-1RA was low from 2013 through 2019, it increased among patients with CVD.

Figure 1

Trends in antidiabetes drug class initiation by quarter in Clinformatics (A) and Medicare (B) databases.

Figure 2

Trends in patients with (A) and without (B) CVD initiating metformin in Clinformatics and with (C) and without (D) CVD in Medicare database.

Figure 3

Trends in patients initiating antidiabetes drugs with or without CV benefits compared with metformin in Clinformatics (A) and Medicare (B) databases. *SGLT-2i and GLP-1RA. **Sulfonylureas, DPP-4i, TZD, and others (α-glucosidase inhibitors, amylin mimetics, dopamine receptor agonists, and meglitinides). ¹Defined as a history of diabetic nephropathy, neuropathy, or retinopathy. ²Defined as a history of myocardial infarction, unstable angina, other ischemic heart diseases, transient ischemic attack, stroke, atherosclerotic peripheral vascular disease, or heart failure. ³Defined as specialist visits occurred within 14 days before cohort entry. ⁴Defined as hospitalization occurred within 180 days before cohort entry. ⁵Defined as having three or more HbA_1c test orders within 365 days before cohort entry.