Advertisement

Low Use of Guideline-recommended Cardiorenal Protective Antihyperglycemic Agents in Primary Care: A Cross-sectional Study of Adults With Type 2 Diabetes

Published:February 15, 2022DOI:https://doi.org/10.1016/j.jcjd.2022.02.002

      Abstract

      Objectives

      Glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) have shown cardiorenal benefits independent of their glucose-lowering effects among persons living with type 2 diabetes mellitus (T2DM). In this study, we describe the proportion of persons with T2DM eligible to receive and currently receiving these agents based on their risk criteria for cardiorenal events.

      Methods

      This study was a cross-sectional analysis of primary care electronic medical records, in southern Alberta, of persons with T2DM who had at least 1 encounter with their primary care provider between December 31, 2018, to December 31, 2020. A descriptive and multivariate logistic regression analysis was conducted to examine clinical and demographic determinants of being prescribed one of the new treatments.

      Results

      Our study sample included 11,939 persons living with T2DM, among whom 66.3% had a cardiorenal indication for SGLT2i or GLP-1 RA use. In the secondary and primary prevention subsamples, 19.4% and 16.6% of persons were prescribed SGLT2i or GLP-1 RA, respectively, compared with 20.0% of those with no specific cardiorenal indication. Several person-level characteristics, such as age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.96 to 0.97), male sex (OR, 1.37; 95% CI, 1.21 to 1.55) and glycated hemoglobin (OR, 1.29; 95% CI, 1.24 to 1.34), were associated with being prescribed SGLT2i or GLP-1 RA.

      Conclusions

      Low rates of SGLT2i or GLP-1 RA use and minimal differences between high-risk and no cardiorenal indication subsamples suggest the presence of barriers to prescribing these medications in a primary care setting. Action to highlight the indications for, and improve access to agents with, cardiorenal benefits will be required to achieve better outcomes for people with T2DM in primary care.

      Résumé

      Objectifs

      Les agonistes des récepteurs du GLP-1 (AR-GLP-1)) et les inhibiteurs du cotransporteur sodium-glucose de type 2 (iSGLT-2) ont montré des bénéfices cardiorénaux indépendamment de leurs effets hypoglycémiants chez les personnes atteintes du diabète sucré de type 2 (DST2). Dans la présente étude, nous décrivons la proportion de personnes atteintes du DST2 admissibles à recevoir ou qui recevaient déjà ces médicaments selon leurs critères de risque d’événements cardiorénaux.

      Méthodes

      Cette étude constituait une analyse transversale de dossiers médicaux électroniques (DME) en soins primaires, dans le sud de l’Alberta, de personnes atteintes du DST2 qui ont eu au moins 1 rencontre avec leur prestataire de soins primaires entre le 31 décembre 2018 et le 31 décembre 2020. Nous avons réalisé une analyse de régression logistique descriptive et multivariée pour examiner les déterminants cliniques et démographiques de la réception d’une ordonnance de l’un des nouveaux traitements.

      Résultats

      Notre échantillon d’étude comptait 11 939 personnes qui vivaient avec le DST2, parmi lesquelles 66,3 % avaient une indication cardiorénale pour utiliser un iSGLT2 ou un AR-GLP-1. Dans les sous-échantillons en prévention secondaire et primaire, 19,4 % et 16,6 % des personnes avaient reçu de façon respective une ordonnance d’iSGLT2 ou d’AR-GLP-1 par rapport à 20,0 % des personnes sans indication cardiorénale particulière. Plusieurs caractéristiques individuelles telles que l’âge (rapport de cotes [RC], 0,96; intervalle de confiance [IC] à 95 %, de 0,96 à 0,97), le sexe masculin (RC, 1,37; IC à 95 %, de 1,21 à 1,55) et l’hémoglobine glyquée (RC, 1,29; IC à 95 %, de 1,24 à 1,34) étaient associées à la réception d’une ordonnance d’i SGLT2 ou d’AR-GLP-1.

      Conclusions

      Les faibles taux d’utilisation d’iSGLT2 ou d’AR-GLP-1 et les différences minimales entre les sous-échantillons de personnes exposées à un risque élevé et de personnes sans indication cardiorénale montrent la présence d’obstacles à la prescription de ces médicaments dans le cadre des soins primaires. Des mesures pour faire valoir les indications, et pour améliorer l’accès aux médicaments, et des bénéfices cardiorénaux seront nécessaires pour optimiser les résultats cliniques chez les personnes atteintes du DST2 dans le cadre des soins primaires.

      Keywords

      Mots clés

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Diabetes
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Public Health Agency of Canada
        Diabetes in Canada: Highlights from the Canadian Chronic Disease Surveillance System.
        • Diabetes Canada Clinical Practice Guidelines Expert Committee
        Pharmacologic glycemic management of type 2 diabetes in adults.
        Can J Diabetes. 2018; 42: S88-S103
        • Alzaid A.
        • Guevara P.L.d.
        • Beillat M.
        • Martin V.L.
        • Atanasov P.
        Burden of disease and costs associated with type 2 diabetes in emerging and established markets: Systematic review analyses.
        Expert Rev Pharmacoecon Outcomes Res. 2021; 21: 785-798
        • Chen H.Y.
        • Kuo S.
        • Su P.F.
        • Wu J.S.
        • Ou H.T.
        Health care costs associated with macrovascular, microvascular, and metabolic complications of type 2 diabetes across time: Estimates from a population-based cohort of more than 0.8 million individuals with up to 15 years of follow-up.
        Diabetes Care. 2020; 43: 1732-1740
        • Rapattoni W.
        • Zante D.
        • Tomas M.
        • et al.
        A retrospective observational population-based study to assess the prevalence and burden of illness of type 2 diabetes with an estimated glomerular filtration rate < 90 mL/min/1.73 m2 in Ontario, Canada.
        Diabetes Obes Metab. 2021; 23: 916-928
        • van Wijngaarden R.P.
        • Overbeek J.A.
        • Heintjes E.M.
        • et al.
        Relation between different measures of glycemic exposure and microvascular and macrovascular complications in patients with type 2 diabetes mellitus: An observational cohort study.
        Diabetes Ther. 2017; 8: 1097-1109
        • Nordwall M.
        • Arnqvist H.J.
        • Bojestig M.
        • Ludvigsson J.
        Good glycemic control remains crucial in prevention of late diabetic complications---the Linköping Diabetes Complications Study.
        Pediatr Diabetes. 2009; 10: 168-176
        • Diabetes Control Complications Trial Research Group
        The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.
        N Engl J Med. 1993; 329: 977-986
        • Bzowyckyj A.
        Managing the multifaceted nature of type 2 diabetes using once-weekly injectable GLP-1 receptor agonist therapy.
        J Clin Pharm Ther. 2020; 45: 7-16
        • Tandon N.
        • Ali M.K.
        • Venkat Narayan K.M.
        Pharmacologic prevention of microvascular and macrovascular complications in diabetes mellitus.
        Am J Cardiovasc Drugs. 2012; 12: 7-22
        • Action to Control Cardiovascular Risk in Diabetes Study Group
        Effects of intensive glucose lowering in type 2 diabetes.
        N Engl J Med. 2008; 358: 2545-2559
        • Ismail-Beigi F.
        • Craven T.
        • Banerji M.A.
        • et al.
        Effect of intensive treatment of hyperglycemia on microvascular outcomes in type 2 diabetes: An analysis of the ACCORD randomised trial.
        Lancet. 2010; 376: 419-430
        • The ADVANCE Collaborative Group
        Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes.
        N Engl J Med. 2008; 358: 2560-2572
        • Zinman B.
        • Wanner C.
        • Lachin J.M.
        • et al.
        Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes.
        N Engl J Med. 2015; 373: 2117-2128
        • Marso S.P.
        • Daniels G.H.
        • Brown-Frandsen K.
        • et al.
        Liraglutide and cardiovascular outcomes in type 2 diabetes.
        N Engl J Med. 2016; 375: 311-322
        • Marso S.P.
        • Bain S.C.
        • Consoli A.
        • et al.
        Semaglutide and cardiovascular outcomes in patients with type 2 diabetes.
        N Engl J Med. 2016; 375: 1834-1844
        • Neal B.
        • Perkovic V.
        • Mahaffey K.W.
        • et al.
        Canagliflozin and cardiovascular and renal events in type 2 diabetes.
        N Engl J Med. 2017; 377: 644-657
        • Hernandez A.F.
        • Green J.B.
        • Janmohamed S.
        • et al.
        Albiglutide and cardiovascular outcomes in patients with type 2 diabetes and cardiovascular disease (Harmony outcomes): A double-blind, randomised placebo-controlled trial.
        Lancet. 2018; 392: 1519-1529
        • Gerstein H.C.
        • Colhoun H.M.
        • Dagenais G.R.
        • et al.
        Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): A double-blind, randomised placebo-controlled trial.
        Lancet. 2019; 394: 121-130
        • McMurray J.J.
        • Solomon S.D.
        • Inzucchi S.E.
        • et al.
        Dapagliflozin in patients with heart failure and reduced ejection fraction.
        N Engl J Med. 2019; 381: 1995-2008
        • Wiviott S.D.
        • Raz I.
        • Bonaca M.P.
        • et al.
        Dapagliflozin and cardiovascular outcomes in type 2 diabetes.
        N Engl J Med. 2019; 380: 347-357
        • Heerspink H.J.
        • Oshima M.
        • Zhang H.
        • et al.
        Canagliflozin reduces kidney-related adverse events in type 2 diabetes and CKD: Findings from the randomized CREDENCE trial.
        Am J Kidney Dis. 2021;
        • Diabetes Canada Clinical Practice Guidelines Expert Committee
        Pharmacologic glycemic management of type 2 diabetes in adults: 2020 update.
        Can J Diabetes. 2020; 44: 575-591
        • Diabetes Canada Clinical Practice Guidelines Steering Committee
        Pharmacologic glycemic management of type 2 diabetes in adults: 2020 update---the user’s guide.
        Can J Diabetes. 2020; 44: 592-596
        • Garies S.
        • Birtwhistle R.
        • Drummond N.
        • Queenan J.
        • Williamson T.
        Data resource profile: national electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN).
        Int J Epidemiol. 2017; 46: 1091-1092f
        • CPCSSN Team
        Case definitions: Canadian Primary Care Sentinel Surveillance Network (CPCSSN), version 2.0. 2019.
      1. Lethebe BC. Using machine learning methods to improve chronic disease case definitions in primary care electronic medical records. Unpublished master's thesis, University of Calgary, Calgary, Alberta, Canada.

        • Williamson T.
        • Green M.E.
        • Birtwhistle R.
        • et al.
        Validating the 8 CPCSSN case definitions for chronic disease surveillance in a primary care database of electronic health records.
        Ann Fam Med. 2014; 12: 367-372
        • Lethebe B.C.
        • Williamson T.
        • Garies S.
        • et al.
        Developing a case definition for type 1 diabetes mellitus in a primary care electronic medical record database: an exploratory study.
        CMAJ Open. 2019; 7: E246-E251
        • Birtwhistle R.V.
        Canadian Primary Care Sentinel Surveillance Network: A developing resource for family medicine and public health.
        Can Fam Physician. 2011; 57: 1219-1220
        • Birtwhistle R.
        • Queenan J.A.
        Update from CPCSSN.
        Can Fam Physician. 2016; 62: 851
        • Birtwhistle R.
        • Keshavjee K.
        • Lambert-Lanning A.
        • et al.
        Building a pan-Canadian primary care sentinel surveillance network: Initial development and moving forward.
        J Am Board Fam Med. 2009; 22: 412-422
        • Birtwhistle R.
        • Morkem R.
        • Peat G.
        • et al.
        Prevalence and management of osteoarthritis in primary care: An epidemiologic cohort study from the Canadian Primary Care Sentinel Surveillance Network.
        CMAJ Open. 2015; 3: E270-E275
        • Drummond N.
        • Birtwhistle R.
        • Williamson T.
        • Khan S.
        • Garies S.
        • Molnar F.
        Prevalence and management of dementia in primary care practices with electronic medical records: A report from the Canadian Primary Care Sentinel Surveillance Network.
        CMAJ Open. 2016; 4: E177-E184
        • Morkem R.
        • Handelman K.
        • Queenan J.A.
        • Birtwhistle R.
        • Barber D.
        Validation of an EMR algorithm to measure the prevalence of ADHD in the Canadian Primary Care Sentinel Surveillance Network (CPCSSN).
        BMC Med Inform Decis Mak. 2020; 20: 166
        • Khatib R.
        • Glowacki N.
        • Lauffenburger J.
        • Siddiqi A.
        Race/ethnic differences in atherosclerotic cardiovascular disease risk factors among patients with hypertension: Analysis from 143 primary care clinics.
        Am J Hypertens. 2021; 34: 948-955
        • Eberly L.A.
        • Yang L.
        • Eneanya N.D.
        • et al.
        Association of race/ethnicity, gender, and socioeconomic status with sodium-glucose cotransporter 2 inhibitor use among patients with diabetes in the US.
        JAMA Netw Open. 2021; 4e216139
        • Vijh R.
        • Wong S.T.
        • Grandy M.
        • et al.
        Identifying heart failure in patients with chronic obstructive lung disease through the Canadian Primary Care Sentinel Surveillance Network in British Columbia: A case derivation study.
        CMAJ Open. 2021; 9: E376-E383
        • CPCSSN Team
        CPCSSN data dictionary (for researchers). Version 4.0.5 2020-Q2. 2020.
        • Gamache P.
        • Hamel D.
        • Blaser C.
        Bureau d’information et d’études en santé des pop. Material and social deprivation index: A summary---INSPQ website. 2019.
        www.inspq.qc.ca/en/publications/2639
        Date accessed: August 8, 2021
      2. Nguyen V, Boucher M. Reimbursement of newer drugs for type 2 diabetes in Canada: An environmental scan. Environmental Scan. No. 84. Ottawa: CADTH, 2019.

        • Dave C.V.
        • Schneeweiss S.
        • Wexler D.J.
        • Brill G.
        • Patorno E.
        Diabetes Care. 2020; 43: 921-924
        • Shin H.
        • Schneeweiss S.
        • Glynn R.J.
        • Patorno E.
        Trends in first-line glucose-lowering drug use in adults with type 2 diabetes in light of emerging evidence for SGLT-21 and GLP-1 RA.
        Diabetes Care. 2021; 44: 1774-1782
        • Greiver M.
        • Havard A.
        • Bowles J.K.
        • et al.
        Trends in diabetes medication use in Australia, Canada, England, and Scotland: A repeated cross-sectional analysis in primary care.
        Br J Gen Pract. 2021; 71: e209-e218
        • Newman T.V.
        • Munshi K.D.
        • Neilson L.M.
        • et al.
        Health care utilization and costs associated with switching from DPP-4i to GLP-1RA or SGLT2i: An observational cohort study.
        J Manag Care Spec Pharm. 2021; 27: 435-443
        • Pittampalli S.
        • Upadyayula S.
        • Mekala H.M.
        • Lippmann S.
        Risks vs benefits for SGLT2 inhibitor medications.
        Fed Pract. 2018; 35: 45
        • Filippatos T.D.
        • Panagiotopoulou T.V.
        • Elisaf M.S.
        Rev Diabet Stud. 2014; 11: 202
        • Nauck M.A.
        • Friedrich N.
        Do GLP-1–based therapies increase cancer risk?.
        Diabetes Care. 2013; 36: S245-S252