Prescription Patterns for Sodium-Glucose Cotransporter 2 Inhibitors in U.S. Health Systems

Abstract

Background: Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce heart failure (HF) hospitalizations, recurrent cardiovascular events, and chronic kidney disease (CKD) progression, and thus constitute a Class 1a recommendation in people with diabetes and atherosclerotic cardiovascular disease, HF, or CKD and in people with severe albuminuria or HF, regardless of diabetes status.

Objectives: The purpose of this study was to comprehensibly characterize the rate of SGLT2 inhibitor prescriptions among people with a Class 1a recommendation for SGLT2 inhibitor use.

Methods: Among 3,189,827 adults from 28 U.S. health systems within Optum Labs Data Warehouse between April 1, 2022, and March 31, 2023, we assessed SGLT2 inhibitor prescription rates, stratified by presence of diabetes and Class 1a recommendation.

Results: Among 716,387 adults with diabetes, 63.4% had a Class 1a recommendation for SGLT2 inhibitor therapy. There was little difference by Class 1a recommendation status (present: 11.9%; 95% CI: 11.9%-12.0% vs absent: 11.4%; 95% CI: 11.3%-11.6%; standardized mean difference: 1.3%). Among 2,473,440 adults without diabetes, 6.2% had a Class 1a recommendation for SGLT2 inhibitor therapy, and 3.1% (3.0%-3.2%) of those received a prescription. Internists/family practitioners initiated SGLT2 inhibitor prescriptions most commonly among people with diabetes, whereas specialists initiated SGLT2 inhibitor prescriptions most commonly among people without diabetes. No health system had >25% SGLT2 inhibitor prescription rate among people with a Class 1a recommendation. Health systems with higher proportions of patients with commercial insurance and lower proportions with Medicare had higher SGLT2 inhibitor prescription rates.

Conclusions: In this analysis of U.S. data from 2022 to 2023, SGLT2 inhibitor prescription among people with a Class 1a recommendation is low. Interventions are needed to increase uptake of guideline-recommended SGLT2 inhibitor use.

Keywords: chronic kidney disease; guidelines; heart failure; prescription; sodium-glucose cotransporter 2 inhibitors; type 2 diabetes.

Figure 1.. Prescription rates of SGLT2-inhibitors and ACEI/ARBs by overlap between indications

This proportional Venn diagram illustrates SGLT2-inhibitor and ACEI/ARB prescription rates by overlap between different indications. The size of the circles represents the sample size of each group. Abbreviations: ACEI, angiotensin-converting enzyme inhibitors; ARB, angiotensin II receptor blockers; ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; HF, heart failure; SGLT2-inhibitor, sodium glucose co-transporter-2 inhibitor; UACR, urine albumin to creatinine ratio

Figure 2.. Variation across 28 health systems in the prescription of SGLT2-inhibitors

The box plots show variability in SGLT2-inhibitor prescription rates across health systems. Each dot indicates a distinct health system. The numbers next to the box represent the median value along with the interquartile interval. Abbreviations: SGLT2-inhibitor, sodium glucose co-transporter-2 inhibitors

Figure 3.. Specialty of providers who initiate SGLT2-inhibitor prescriptions

This figure illustrates the types of providers initiating SGLT2-inhibitor therapy by presence of diabetes and a class 1A recommendation. Abbreviations: SGLT2-inhibitor, sodium glucose co-transporter-2 inhibitor

Central Illustration.. Sodium Glucose Cotransporter-2-Inhibitor Use in US Health Systems in 2022–2023

This large-scale analysis of data from 28 US health systems demonstrates that guideline-recommended prescription of SGLT2-inhibitor in people with a class 1A recommendation is only 11.9% in people with diabetes and only 3.1% in people without diabetes. There was significant variability across health systems, but none of them prescribed SGLT2-inhibitors to more than 25% of the population with a class 1A recommendation. The most common provider to initiate guideline-recommended SGLT2-inhibitor therapy was an internist or family practitioner (46.7%) in people with diabetes and a cardiologist (51.8%) in people without diabetes. Abbreviations: SGLT2-inhibitor, sodium glucose co-transporter-2 inhibitor