Prescription Patterns of Novel Antihyperglycemic Medications

Arif S. Ali; Madiha Khan; Danielle Ortega; Syed Jaffery; Lois E. Lamerato; Katarzyna Budzynska

doi:10.3122/jabfm.2022.02.210360

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Figure 1.
Attrition diagram for study population sample selection. Abbreviations: BMI, body mass index; eGFR, estimated glomerular filtration rate; HbA1c, hemoglobin A1c; DM2, diabetes mellitus type 2.

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Table 1.

Baseline Characteristics

Clinical and sociodemographic characteristics	Total Population N = 31354 (%)	Pts on GLP-1a Agonist N = 1066 (%)	Pts on SGLT-2i Inhibitor N = 673 (%)	Pts on Neither GLP-1a nor SGLT-2i N = 29757 (%)
Gender
Male	15020 (47.9%)	458 (43.0%)	364 (54.1%)	14272 (48.0%)
Female	16334 (52.1%)	608 (57.0%)	309 (45.9%)	15485 (52.0%)
Age strata
Age 40 to 49	3566 (11.4%)	181 (15.1%)	114 (16.9%)	3317 (11.1%)
Age 50 to 59	7756 (24.7%)	341 (32.0%)	263 (39.1%)	7207 (24.2%)
Age 60 to 69	11562 (36.9%)	436 (40.9%)	229 (34.0%)	10953 (36.8%)
Age 70 to 79	8470 (27.0%)	128 (12.0%)	67 (10.0%)	8280 (27.8%)
Race
African American	12778 (40.8%)	328 (30.8%)	113 (16.8%)	12.360 (41.5%)
White	18576 (59.2%)	738 (69.2%)	560 (83.2%)	17397 (58.5%)
BMI (kg/m²) mean (S.D.)	34.15 (7.48)	37.15 (7.79)	35.96 (7.34)	34.02 (7.45)
BMI strata
BMI < 18.5 (Underweight)	80 (0.3%)	0 (0.0%)	0 (0.0%)	80 (0.3%)
BMI 18.5 to 24.9 (Normal)	2350 (7.5%)	24 (2.3%)	20 (3.0%)	2309 (7.8%)
BMI 25.0 to 29.9 (Overweight)	7437 (23.7%)	149 (14.0%)	117 (17.4%)	7191 (24.2%)
BMI 30.0 to 39.9 (Obese)	15374 (49.0%)	547 (51.3%)	360 (53.5%)	14540 (48.9%)
BMI 40.0 to 49.9 (Morbidly obese)	6113 (19.5%)	346 (32.5%)	176 (26.2%)	5637 (18.9%)
HbA1c mean (S.D.)	7.7 (1.92)	8.4 (1.75)	8.4 (1.81)	7.7 (1.93)
HbA1c ≤ 7.0% (≤53 mmol/mol)	14750 (47.0%)	241 (22.6%)	168 (25.0%)	14367 (48.3%)
HbA1c 7.1 to 8.9% (54 to 74 mmol/mol)	10467 (33.4%)	475 (44.6%)	308 (45.8%)	9752 (32.8%)
HbA1c ≥ 9.0% (≥75 mmol/mol)	6137 (19.6%)	350 (32.8%)	197 (29.3%)	5638 (18.9%)
History of hypertension	25292 (80.7%)	873 (81.9%)	532 (79.0%)	24001 (80.7%)
History of ASCVD	9557 (30.5%)	288 (27.0%)	123 (18.3%)	9172 (30.8%)
Cigarette use
Never used cigarettes	14661 (46.8%)	571 (53.6%)	339 (50.4%)	13818 (46.4%)
Current cigarette use	5185 (16.5%)	113 (10.6%)	99 (14.7%)	4993 (16.8%)
Former cigarette use	11456 (36.5%)	382 (35.8%)	233 (34.6%)	10896 (36.6%)
Missing	52 (0.2%)	0 (0.0%)	2 (0.3%)	50 (0.2%)
Current statin use	20591 (65.7%)	777 (72.9%)	437 (64.9%)	19.471 (85.4%)
CKD Stage 1 (eGFR ≥90)	11934 (38.1%)	500 (46.9%)	331 (49.2%)	11183 (37.6%)
CKD Stage 2 (eGFR 60 to 89)	12913 (41.2%)	383 (35.9%)	284 (42.2%)	12295 (41.3%)
CKD Stage 3a (eGFR 45 to 59)	3597 (11.5%)	124 (11.6%)	47 (7.0%)	3439 (11.6%)
CKD Stage 3b (eGFR 30 to 44)	1750 (5.6%)	52 (4.9%)	10 (1.5%)	1688 (5.7%)
CKD Stage 4 (eGFR 15 to 29)	653 (2.1%)	6 (0.6%)	1 (0.1%)	646 (2.2%)
CKD Stage 5 (eGFR <15)	507 (1.6%)	1 (0.1%)	0 (0.0%)	506 (1.7%)
eGFR (mL/min) mean (S.D.)	79.07 (24.59)	83.67 (22.27)	86.78 (18.40)	78.78 (24.74)
Median Household Income from Census mean, (S.D.)	52577.82 (25916.15)	58138.43 (28047.15)	58116.94 (24179.18)	52282.99 (25840.50)
Income strata
Income <$27000	4484 (14.3%)	99 (9.3%)	49 (7.3%)	4346 (14.6%)
Income $27000 to 44999	9255 (29.5%)	274 (25.7%)	159 (23.6%)	8857 (29.8%)
Income $45000 to 65999	9560 (30.5%)	350 (32.8%)	240 (35.7%)	9017 (30.3%)
Income ≥$66000	7964 (25.4%)	339 (31.8%)	223 (33.1%)	7452 (25.0%)
Missing	52 (0.2%)	4 (0.4%)	2 (0.3%)	85 (0.3%)
Insurance
Commercial Insurance	13338 (42.9%)	594 (55.7%)	455 (67.6%)	12391 (41.6%)
Medicaid Insurance	3078 (9.9%)	77 (7.2%)	37 (5.5%)	2969 (10.0%)
Medicare Insurance	14694 (47.2%)	386 (36.2%)	177 (26.3%)	14165 (47.6%)
Missing	243 (0.8%)	9 (0.8%)	4 (0.6%)	232 (0.8%)
Glucose lowering medications prescribed
Metformin	19341 (61.7%)	767 (72.0%)	504 (74.9%)	18178 (61.1%)
Secretagogues	8069 (25.7%)	338 (31.7%)	258 (38.3%)	7525 (25.3%)
DPP-4	2439 (7.8%)	132 (12.4%)	208 (30.9%)	2135 (7.2%)
α-glucosidase inhibitor	64 (0.2%)	5 (0.5%)	2 (0.3%)	57 (0.2%)
Thiazolidinediones	536 (1.7%)	35 (3.3%)	19 (2.8%)	485 (1.6%)
Insulin	13141 (41.9%)	698 (65.5%)	318 (47.3%)	12209 (41.0%)
GLP-1a agonist	1066 (3.4%)
SGLT-2i inhibitor	673 (2.1%)

Abbreviations: DPP-4, Dipeptidyl peptidase-4 inhibitor; ASCVD, atherosclerotic cardiovascular disease; BMI, body mass index; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; GLP-1a, glucagon-like peptide 1; HbA1c, hemoglobin A1c; SGLT-2i, sodium glucose cotransporter-2.

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Table 2.

Logistic Regression GLP-1a

Covariate	Beta (S.E.)	Odds Ratio (95% CI)	p-Value
Age 40 to 49	Reference Category
Age 50 to 59	0.223 (0.058)	0.995 (0.814, 1.215)	<0.001
Age 60 to 69	0.144 (0.052)	0.920 (0.743, 1.139)	0.006
Age 70 to 79	−0.595 (0.086)	0.439 (0.329, 0.586)	<0.001
Race: African American	−0.223 (0.038)	0.640 (0.552, 0.741)	<0.001
Race: White	Reference Category
Gender: Male	−0.164 (0.033)	0.721 (0.633, 0.821)	<0.001
Gender: Female	Reference Category
Hypertension: Present	0.033 (0.043)	1.069 (0.902, 1.267)	0.441
Statin Prescribed: Yes	0.152 (0.037)	1.356 (1.173, 1.568)	<0.001
Insulin Prescribed: Yes	0.435 (0.036)	2.389 (2.075, 2.750)	<0.001
History of ASCVD: Yes	−0.024 (0.038)	0.954 (0.821, 1.108)	0.536
Metformin Prescribed: Yes	0.126 (0.037)	1.286 (1.111, 1.488)	<0.001
BMI < 18.5 (Underweight)	−9.024 (166.7)	N/A *	0.957
BMI 18.5 to 24.9 (Normal)	Reference Category
BMI 25.0 to 29.9 (Overweight)	2.112 (41.683)	1.796 (1.160, 2.781)	0.960
BMI 30.0 to 39.9 (Obese)	2.515 (41.682)	2.687 (1.773, 4.073)	0.952
BMI 40.0 to 49.9 (Morbidly obese)	2.870 (41.682)	3.834 (2.509, 5.859)	0.945
Lifetime Non-smoker	Reference Category
Former Cigarette Smoker	0.144 (0.051)	0.960 (0.836, 1.102)	0.005
Active Cigarette Smoker	−0.329 (0.069)	0.598 (0.485, 0.739)	<0.001
CKD Stage 1 (eGFR ≥90)	Reference Category
CKD Stage 2 (eGFR 60 to 89)	0.561 (0.190)	0.802 (0.692, 0.929)	0.003
CKD Stage 3a (eGFR 45 to 59)	0.692 (0.199)	0.914 (0.733, 1.140)	<0.001
CKD Stage 3b (eGFR 30 to 44)	0.536 (0.218)	0.782 (0.571, 1.070)	0.014
CKD Stage 4 (eGFR 15 to 29)	−0.650 (0.384)	0.239 (0.105, 0.543)	0.091
CKD Stage 5 (eGFR <15)	−1.922 (0.839)	0.067 (0.009, 0.480)	0.022
HbA1c ≤ 7.0% (≤53 mmol/mol)	Reference Category
HbA1c 7.1 to 8.9% (54 to 74 mmol/mol)	0.244 (0.043)	2.209 (1.877, 2.599)	<0.001
HbA1c ≥ 9.0% (≥75 mmol/mol)	0.305 (0.049)	2.349 (1.960, 2.814)	<0.001
Income <$27000	Reference Category
Income $27000 to 44999	−0.096 (0.057)	1.163 (0.914, 1.479)	0.092
Income $45000 to 65999	0.080 (0.055)	1.387 (1.088, 1.767)	0.145
Income ≥$66000	0.263 (0.057)	1.666 (1.300, 2.135)	<0.001
Commercial Insurance	Reference Category
Medicaid	−0.290 (0.126)	0.599 (0.466, 0.768)	0.022
Medicare	0.061 (0.104)	0.850 (0.727, 0.993)	0.559
Other/Unknown	0.005 (0.261)	0.804 (0.407, 1.588)	0.985

Abbreviations: ASCVD, atherosclerotic cardiovascular disease; BMI, body mass index; CI, confidence interval; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; GLP-1a, glucagon-like peptide 1; HbA1c, hemoglobin A1c; N/A, not available; S.E., standard error.

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Table 3.

Logistic Regression SGLT-2i

Covariate	Beta (S.E.)	Odds Ratio (95% CI)	p-Value
Age 40 to 49	Reference Category
Age 50 to 59	0.323 (0.070)	1.001 (0.794, 1.262)	<0.001
Age 60 to 69	−0.032 (0.068)	0.702 (0.542, 0.910)	0.639
Age 70 to 79	−0.613 (0.114)	0.393 (0.272, 0.567)	<0.001
Race: African American	−0.631 (0.056)	0.283 (0.227, 0.353)	<0.001
Race: White	Reference Category
Gender: Male	0.019 (0.041)	1.040 (0.885, 1.221)	0.636
Gender: Female	Reference Category
Hypertension: Present	0.110 (0.051)	1.245 (1.020, 1.520)	0.031
Statin Prescribed: Yes	0.006 (0.043)	1.013 (0.855, 1.200)	0.883
Insulin Prescribed: Yes	0.115 (0.03)	1.259 (1.064, 1.489)	0.007
History of ASCVD: Yes	−0.193 (0.054)	0.679 (0.550, 0.839)	<0.001
Metformin Prescribed: Yes	0.098 (0.047)	1.217 (1.011, 1.465)	0.038
BMI < 18.5 (Underweight)	−9.630 (335.5)	N/A *	0.977
BMI 18.5 to 24.9 (Normal)	Reference Category
BMI 25.0 to 29.9 (Overweight)	2.369 (83.867)	1.537 (0.950, 2.487)	0.978
BMI 30.0 to 39.9 (Obese)	2.592 (83.866)	1.922 (1.215, 3.042)	0.975
BMI 40.0 to 49.9 (Morbidly obese)	2.729 (83.866)	2.205 (1.370, 3.546)	0.974
Lifetime Non-smoker	Reference Category
Former Cigarette Smoker	0.057 (0.061)	1.010 (0.848, 1.203)	0.353
Active Cigarette Smoker	−0.104 (0.076)	0.860 (0.681, 1.086)	0.173
CKD Stage 1 (eGFR ≥90)	Reference Category
CKD Stage 2 (eGFR 60 to 89)	2.647 (28.213)	1.039 (0.872, 1.238)	0.925
CKD Stage 3a (eGFR 45 to 59)	2.290 (28.213)	0.727 (0.523, 1.010)	0.935
CKD Stage 3b (eGFR 30 to 44)	1.527 (28.214)	0.339 (0.177, 0.648)	0.957
CKD Stage 4 (eGFR 15 to 29)	0.270 (28.224)	0.096 (0.013, 0.694)	0.992
CKD Stage 5 (eGFR <15)	−9.342 (141.1)	N/A *	0.947
HbA1c ≤ 7.0% (≤53 mmol/mol)	Reference Category
HbA1c 7.1 to 8.9% (54 to 74 mmol/mol)	0.265 (0.054)	2.269 (1.866, 2.761)	<0.001
HbA1c ≥ 9.0% (≥75 mmol/mol)	0.290 (0.063)	2.328 (1.859, 2.914)	<0.001
Income <$27000	Reference Category
Income $27000 to 44999	−0.100 (0.075)	0.957 (0.686, 1.335)	0.182
Income $45000 to 65999	0.043 (0.069)	1.104 (0.795, 1.533)	0.533
Income ≥$66000	0.113 (0.072)	1.184 (0.848, 1.654)	0.115
Commercial Insurance	Reference Category
Medicaid	−0.336 (0.182)	0.414 (0.292, 0.585)	0.064
Medicare	0.058 (0.152)	0.613 (0.499, 0.754)	0.704
Other/Unknown	−0.268 (0.384)	0.443 (0.163, 1.203)	0.485

Abbreviations: ASCVD, atherosclerotic cardiovascular disease; BMI, body mass index; CI, confidence interval; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; HbA1c, hemoglobin A1c; N/A, not available; SGLT-2i, sodium glucose cotransporter-2; S.E., standard error.

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Appendix:

Bivariate Analysis for Use of GLP-1a or SGLT-2i

Characteristic	Patients on GLP-1a or SGLT-2i (%)	Patients Not on GLP-1a or SGLT-2i (%)	p-Value
Gender			0.38
Male	748 (5.0)	14272 (95.0)
Female	849 (5.2)	15485 (94.8)
Race
African American	418 (3.3)	12360 (96.7)	<0.05
White	1179 (6.3)	17397 (93.7)
Age strata
Age 40 – 49	249 (7.0)	3317 (93.0)	<0.05
Age 50 – 59	549 (7.1)	7207 (92.9)
Age 60 – 60	609 (5.3)	10953 (94.7)
Age 70 – 79	190 (2.2)	8280 (97.8)
Insurance
Commercial	947 (59.7)	12391 (42.0)	< 0.05
Medicaid	110 (6.9)	2969 (10.1)
Medicare	529 (33.4)	14165 (48.0)
Income strata
Income < $27000	138 (3.1)	4346 (96.6)	< 0.05
Income $27000 – 44999	398 (4.3)	8857 (95.7)
Income $45000 – 65999	543 (5.7)	9017 (94.3)
Income > $66,000	512 (6.4)	7, 452 (93.6)
BMI strata
BMI < 18.5	0 (0.0)	80 (100.0)	< 0.05
BMI 18.5 – 24.9	41 (1.7)	2309 (98.3)
BMI 25.0 – 29.9	246 (3.3)	7191 (96.7)
BMI 30.0 – 39.9	834 (5.4)	14540 (94.6)
BMI 40.0 – 49.9	476 (7.8)	5637 (92.2)
HbA1c category
HbA1c < 7.0%	383 (2.6)	14367 (97.4)	<0.05
HBbA1c 1,1 – 8.9%	715 (6.8)	9572 (93.2)
HbA1c > 9.0%	499 (8.1)	5638 (91.9)
CKD Stage
CKD Stage 1 (eGFR >90)	751 (6.3)	11183 (93.7)	< 0.05
CKD Stage 2 (eGF 60 – 89)	618 (4.8)	12295 (95.2)
CKD Stage 3a (eGFR 45 – 59)	158 (4.4)	3439 (95.6)
CKD Stage 3b (eGFR 30 – 44)	62 (3.5)	1688 (96.5)
CKD Stage 4 (eGFR 15 – 29)	7 (1.1)	646 (98.9)
CKD Stage 5 (eGFR <15)	1 (0.2)	506 (99.8)
Hypertension	1281 (80.8)	24001 (80.7)	0.86
ASCVD	385 (24.1)	9172 (30.8)	<0.05
Current Cigarette Use	192 (12.0)	4993 (16.8)	<0.05
Statin Use	1120 (70.1)	19471 (65.4)	<0.05
Metformin Use	1163 (72.8)	18178 (61.1)	<0.05
Insulin Use	932 (58.4)	12209 (41.0)	<0.05

Abbreviations: GLP-1a, glucagon-like peptide 1; SGLT-2i, sodium glucose cotransporter-2; BMI, body mass index; HbA1c, hemoglobin A1c; ASCVD, Atherosclerotic cardiovascular disease.