Abstract
Glucagonlike peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT2i), and dipeptidyl peptidase-4 inhibitors (DPP-4i) are associated with low rates of hypoglycemia, and postmarketing trials of GLP-1RA and SGLT2i demonstrated that these medications improved cardiovascular and kidney outcomes. To compare trends in initiation of treatment with GLP-1RA, SGLT2i, and DPP-4i by older adults with type 2 diabetes insured by Medicare Advantage vs commercial health plans. This retrospective cohort study used administrative claims data from a deidentified database of commercially insured and Medicare Advantage beneficiaries. Adults aged 58 to 66 years with type 2 diabetes who filled any medication prescription to lower glucose levels from January 1, 2016, to December 31, 2019, were compared between groups. Enrollment in a Medicare Advantage or commercial health insurance plan. The odds of initiating GLP-1RA, SGLT2i, and DPP-4i treatment were examined for Medicare Advantage vs commercial insurance beneficiaries using 3 separate logistic regression models adjusted for year and demographic and clinical factors. These models were used to calculate adjusted annual rates of medication initiation by health plan. A total of 382 574 adults with pharmacologically treated type 2 diabetes (52.9% men; mean [SD] age, 62.4 [2.7] years) were identified, including 172 180 Medicare Advantage and 210 394 commercial beneficiaries. From 2016 to 2019, adjusted rates of initiation of GLP-1RA, SGLT2i, and DPP-4i treatment increased among all beneficiaries, from 2.14% to 20.02% for GLP-1RA among commercial insurance beneficiaries and from 1.50% to 11.44% among Medicare Advantage beneficiaries; from 2.74% to 18.15% for SGLT2i among commercial insurance beneficiaries and from 1.57% to 8.51% among Medicare Advantage beneficiaries; and from 3.30% to 11.71% for DPP-4i among commercial insurance beneficiaries and from 2.44% to 7.68% among Medicare Advantage beneficiaries. Initiation rates for all 3 drug classes were consistently lower among Medicare Advantage than among commercial insurance beneficiaries. Within each calendar year, the odds of initiating GLP-1RA treatment ranged from 0.28 (95% CI, 0.26-0.29) to 0.70 (95% CI, 0.65-0.75) for Medicare Advantage and commercial insurance beneficiaries, respectively; SGLT2i, from 0.21 (95% CI, 0.20-0.22) to 0.57 (95% CI, 0.53-0.61), respectively; and DPP-4i, from 0.37 (95% CI, 0.34-0.39) to 0.73 (95% CI, 0.69-0.78), respectively (P < .001 for all). The odds of starting GLP-1RA and SGLT2i increased with income; for an income of $200 000 and higher vs less than $40 000, the odds ratio for GLP-1RA was 1.23 (95% CI, 1.15-1.32) and for SGLT2i was 1.16 (95% CI, 1.09-1.24). These findings suggest that Medicare Advantage beneficiaries may be less likely than commercially insured beneficiaries to be treated with newer medications to lower glucose levels, with greater disparities among lower-income patients. Better understanding of nonclinical factors contributing to treatment decisions and efforts to promote greater equity in diabetes management appear to be needed.
Highlights
Type 2 diabetes is one of the most common and serious chronic health conditions in the US,[1] with a disproportionately high burden of disease among older adults
The odds of starting Glucagonlike peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) increased with income; for an income of $200 000 and higher vs less than $40 000, the odds ratio for GLP-1RA was 1.23 and for SGLT2i was 1.16
Contemporary approaches to managing type 2 diabetes take into consideration the need to control hyperglycemia and the effects that chosen therapies may have on outcomes that matter to people with diabetes, such as cardiovascular events, kidney disease progression, and death.[3,4,5,6]
Summary
Type 2 diabetes is one of the most common and serious chronic health conditions in the US,[1] with a disproportionately high burden of disease among older adults. More than 1 in 4 older adults have diabetes (26.8% of US residents 65 years or older),[1] and nearly 90% of older adults with a diagnosis of diabetes are taking medications to lower glucose levels.[2] Optimal diabetes management is predicated on controlling hyperglycemia, avoiding hypoglycemia, and using medications associated with the greatest benefit and the least risk of harm when contextualized against each patient’s preferences and situation. Metformin is consistently recommended as the first-line drug in the management of type 2 diabetes, clinical guidelines advise that the choice of second-line therapy to be used when metformin is either no longer sufficient or is not tolerated is informed by the presence of key comorbidities (ie, cardiovascular disease, heart failure, and nephropathy or chronic kidney disease), risk for hypoglycemia, and considerations of affordability.[3,4,5,6,7] Three classes of medications to lower glucose levels were introduced into practice during the past 2 decades. Glucagonlike peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT2i), and dipeptidyl peptidase-4 inhibitors (DPP-4i) are associated with low rates of hypoglycemia, and postmarketing trials of GLP-1RA and SGLT2i demonstrated that these drugs improved cardiovascular, kidney, and mortality outcomes.[8,9,10,11,12,13,14,15,16,17,18,19,20,21]
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