Contemporary National Patterns of Eligibility and Use of Novel Cardioprotective Antihyperglycemic Agents in Type 2 Diabetes Mellitus
Open accessAbstract
Background: SGLT‐2 (sodium glucose transporter‐2) inhibitors and GLP‐1RAs (glucagon‐like peptide‐1 receptor agonists) effectively lowered cardiovascular risk in large clinical trials for patients with type 2 diabetes mellitus at high risk for these complications, and have been recommended by guidelines. To evaluate the contemporary landscape in which these recommendations would be implemented, we examined the use of these medications according to clinical guideline practice. Methods and Results: In the National Health and Nutrition Examination Survey for 2017 to 2018, we defined compelling indications for SGLT‐2 inhibitors by the presence of atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, and for GLP‐1RAs by the presence of established or high‐risk atherosclerotic cardiovascular disease, based on large clinical trials that have been incorporated in guideline recommendations of the American College of Cardiology and American Diabetes Association. We then evaluated use of these medications among patients with physician‐diagnosed type 2 diabetes mellitus. All analyses incorporated complex survey design to produce nationally representative estimates. A total 1104 of 9254 sampled individuals had type 2 diabetes mellitus, representing 10.6% (95% CI, 9.7%–11.6%) of the US population or 33.2 million adults nationally. Of these, 52.6% (95% CI, 47.7%–57.5%) had an indication for SGLT‐2 inhibitors, 32.8% (95% CI, 28.8%–37.2%) for GLP‐1RAs, and 26.6% (95% CI, 22.2%–31.7%) for both medications. During 2017 to 2018, 4.5% (95% CI, 2.4%–8.2%) were treated with SGLT‐2 inhibitors and 1.5% (95% CI, 0.7%–3.2%) with GLP‐1RAs. Atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease were not independently associated with SGLT‐2 inhibitor or GLP‐1RA use in patients with diabetes mellitus. Conclusions: Despite a large number of patients being eligible for guideline‐recommended cardiorenal protective therapies, there are substantial gaps in the use of SGLT‐2 inhibitors and GLP‐1RAs, limiting their public health benefits.
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Only 1 in 10 patients with type 2 diabetes receives either an SGLT2i or GLP1ra medication.
“Although > 80% of patients with type 2 diabetes are eligible for these medications due to the presence of cardiovascular or renal risk factors, only 1 in 10 patients receives either an SGLT2i or GLP1ra medication.12,13”
From Disparities in Use of Novel Diabetes Medications by Insurance: A Nationally Representative Cohort Study (2024) · cites this paper as [12]
The Results section (Use of SGLT‐2 Inhibitors and GLP‐1RAs From 2017 to 2018) reports use of 4.5% and 1.5%, respectively, with 0.2% receiving both. That implies approximately 5.8% received either medication—closer to 1 in 17 than 1 in 10. (LLM, conf=0.87)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredMore than 80% of patients with type 2 diabetes are eligible for SGLT2i or GLP1ra due to the presence of cardiovascular or renal risk factors.
“Although > 80% of patients with type 2 diabetes are eligible for these medications due to the presence of cardiovascular or renal risk factors, only 1 in 10 patients receives either an SGLT2i or GLP1ra medication.12,13”
From Disparities in Use of Novel Diabetes Medications by Insurance: A Nationally Representative Cohort Study (2024) · cites this paper as [12]
The Results section reports that 52.6% of patients had an indication for SGLT2 inhibitors, 32.8% for GLP-1RAs, and 26.6% for both. Accounting for the overlap, 58.8% were eligible for either medication—not more than 80%. (LLM, conf=0.91)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredOther studies have demonstrated low rates of SGLT2i and GLP1ra medication use (11.2% and 8%, respectively), even among patients at high risk of cardiovascular disease.
“Consistent with our findings, other studies have demonstrated low rates of SGLT2i and GLP1ra medication use (11.2% and 8%, respectively), even among patients at high risk of cardiovascular disease.12–16,32”
From Disparities in Use of Novel Diabetes Medications by Insurance: A Nationally Representative Cohort Study (2024) · cites this paper as [12]
The Results section, “Use of SGLT-2 Inhibitors and GLP-1RAs From 2017 to 2018” (page unavailable), supports low use among eligible patients, including those with cardiovascular indications. It reports 7.0% SGLT2i use and 1.3% GLP-1RA use among eligible patients—not the attributed 11.2% and 8%. The Discussion mentions an approximately 8%–9% GLP-1RA rate from a prior registry, not this study’s estimate. (LLM, conf=0.88)
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- Authors
- Nargesi, A. A., Jeyashanmugaraja, G. P., Desai, N., Lipska, K., Krumholz, H., & Khera, R.
- Affiliations
- Yale University (US)
- Bridgeport Hospital (US)
- Yale New Haven Hospital (US)
- Corresponding author
- Khera, Rohan
- ORCID
- Venue
- Journal of the American Heart Association
- Published
- 2021-07-06
- Volume
- 10
- Issue
- 13
- Pages
- e021084-e021084
- ISSN
- 2047-9980 (ISSN-L)
- PMC
- PMC8403287
- OpenAlex
- W3160152094
- Cited by
- 61
- References
- 24
- Citations by year
- 2026: 3 · 2025: 15 · 2024: 14 · 2023: 16 · 2022: 12 · 2021: 1
- FWCI
- 8.04
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by-nc-nd
- Locations
- Journal of the American Heart Association (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Funders
- National Institutes of Health (UL1TR001863)
- National Institute on Aging (K23AG048359, P30AG021342)
- National Heart, Lung, and Blood Institute (K23HL153775)
- National Center for Advancing Translational Sciences
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Keywords
- SGLT2 inhibitors, GLP-1 receptor agonists, guideline adherence, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, cardiovascular risk, NHANES, United States
- MeSH terms
- Glucagon-Like Peptide-1 Receptor, Sodium-Glucose Transporter 2 Inhibitors, Heart Disease Risk Factors, Glucagon-Like Peptide-1 Receptor Agonists, Aged, Blood Glucose, Cardiovascular Diseases, Diabetes Mellitus, Type 2, Drug Utilization, Eligibility Determination, Female, Humans, Male, Middle Aged, Nutrition Surveys, Practice Patterns, Physicians', Time Factors, United States, Biomarkers, Treatment Outcome, Practice Guidelines as Topic, Risk Assessment, Guideline Adherence, Incretins
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