Prescribing of Newer Diabetes Drugs Not Up to Snuff in Black Patients?

Study among veterans suggests disparities in prescription rates for these type 2 diabetes drugs

Prescriptions for SGLT2 inhibitors and GLP-1 receptor agonists were not equitable across racial groups, according to an analysis of Veterans Health Administration (VHA) data.

Compared with white patients, Black patients had the lowest odds of being prescribed SGLT2 inhibitors (adjusted OR 0.72, 95% CI 0.71-0.74) and GLP-1 receptor agonists (aOR 0.64, 95% CI 0.63-0.66) for their type 2 diabetes, after adjusting for patient-level and system-level factors, reported Julio A. Lamprea-Montealegre, MD, MPH, PhD, of the University of California San Francisco, and colleagues.

Hispanic and Latino patients were also significantly less likely to be prescribed an SGLT2 inhibitor (OR 0.90, 95% CI 0.88-0.93) or a GLP-1 receptor agonist (OR 0.88, 95% CI 0.85-0.91) compared with non-Hispanic or Latino patients, they noted in JAMA.

“These results are consistent with recent research that found low prescription rates of SGLT2 inhibitors and GLP-1 receptor agonists among racial and ethnic minority groups in commercial and Medicare Advantage health plans,” Lamprea-Montealegre’s group wrote. “Given the high cost-sharing for these medications, this study extends these findings to the VHA where the financial constraints impeding medication access are minimized.”

That being said, they also noted that prescription rates for these agents were surprisingly low across the board — especially for patients with comorbid atherosclerotic cardiovascular disease (ASCVD), heart failure, and chronic kidney disease (CKD), for which these agents are recommended for use by clinical practice guidelines — though rates were still the lowest for racial minorities.

Compared with white patients, Black patients with any three of these conditions were significantly less likely to be prescribed an SGLT2 inhibitor:

• ASCVD: aOR 0.72 (95% CI 0.69-0.75)
• Heart failure: aOR 0.84 (95% CI 0.78-0.89)
• CKD: aOR 0.80 (95% CI 0.77-0.83)

The same trends were again seen for GLP-1 receptor agonists:

• ASCVD: aOR 0.63 (95% CI 0.60-0.66)
• Heart failure: aOR 0.66 (95% CI 0.61-0.71)
• CKD: aOR 0.62 (95% CI 0.59-0.65)

“Given mounting evidence supporting the use of SGLT2 inhibitors and GLP-1 receptor agonists in type 2 diabetes, this study provides a timely contribution to the science of pharmacoequity,” wrote Utibe R. Essien, MD, MPH, of the VA Pittsburgh Healthcare System in Pennsylvania, and colleagues in an accompanying editorial.

However, they pointed out that the study didn’t control for dual enrollment in Medicare, which accounts for about 60% of VHA enrollees — a possible contributing factor to the low prescription rates of these agents.

“Repeatedly, as novel, effective, and often costly drugs are approved for use and incorporated into clinical practice guidelines, a disturbing pattern of care is evident,” they noted. “Uptake and diffusion of recommended, evidence-based therapies increase over time, while individuals from underrepresented racial and ethnic groups have lower receipt of these medications.”

“This phenomenon, demonstrated across myriad clinical conditions and therapeutic classes, results in persistent disparities in access to high-quality medications, likely having a critical role in the disparate health seen in underrepresented racial and ethnic groups in the U.S.,” Essien’s group wrote.

Because of this, “prioritizing equity across the therapeutic continuum” should be of vital importance, they added.

This cross-sectional study included data from the VHA’s Corporate Data Warehouse on 1,197,914 patients with type 2 diabetes and at least two primary care clinic visits from January 2019 through December 2020. Mean age was 68, 96% were men, 20% were Black, 7% were Hispanic or Latino, and 71% were white.

SGLT2 inhibitor use was defined as an active prescription for one of the following agents: ertugliflozin (Steglatro), canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance), while GLP-1 receptor agonist use included semaglutide (Ozempic), liraglutide (Victoza), albiglutide (Tanzeum), and dulaglutide (Trulicity).

Of these patients, 11.3% and 8.2% of white patients were prescribed an SGLT2 inhibitor or GLP-1 receptor agonist, respectively, while prescription rates were only 8.8% and 6.1% among Black patients.

Lamprea-Montealegre and colleagues noted that racial and ethnic disparities in the VHA system are less pronounced than in other U.S. health systems, which may have affected the generalizability of their results. In addition, as in all studies involving the VHA, women made up a tiny proportion of patients.