Women, Black, and Asian Patients Least Likely to Get SGLT2 Inhibitors

Marlene Busko

April 23, 2021

In a large cohort of insured American patients with type 2 diabetes, those who were Black, Asian, female, or living in a low-income household were less likely to undergo treatment with a sodium-glucose cotransporter 2 (SGLT2) inhibitor from 2015 (the year that the results of the EMPA-REG trial were published) to 2019.

Moreover, these treatment disparities persisted among patients with heart failure with reduced ejection fraction (HFrEF), atherosclerotic cardiovascular disease (ASCVD), or chronic kidney disease (CKD), who would be most likely to benefit from these newer glucose-lowering agents.

The study, by cardiology fellow Lauren Eberly, MD, MPH, University of Pennsylvania, Philadelphia, Pennsylvania, and colleagues, was published online April 15 in JAMA Network Open.

"If left unaddressed, these inequities in utilization will continue to widen well-documented disparities in cardiovascular and kidney outcomes in the [United States]," she warned in a statement from the university.

"Study after study, including large randomized trials, have demonstrated a cardio-protective and kidney-protective effect of this class of medications," and "we know that Black patients have higher rates of heart failure and kidney disease," Eberly noted.

"This is a therapy we know prevents death from those conditions and prevents progression from those conditions," she continued, yet Black patients, female patients, and those of lower socioeconomic status were less likely to receive it.

The findings "are consistent with prior studies that have shown decreased use of novel therapies among Black patients," senior author Srinath Adusumalli, MD, assistant professor of clinical medicine, Division of Cardiovascular Medicine, University of Pennsylvania, noted.

"Implementation strategies that prioritize not only delivery of guideline-directed care but also equitable guideline-directed care are critical in ensuring all patients have access to evidence-based therapies" he stressed.

Endocrinologists Most Likely to Prescribe SGLT2 Inhibitors

Historically, Black patients, female patients, and those who are poorer have been less likely to receive novel therapies, the researchers write.

They examined the likelihood of being prescribed an SGLT2 inhibitor from 2015 to 2019. Their analysis utilized data from the national Optum Clinformatics Data Mart database.

The investigators identified 934,737 patients with type 2 diabetes who were continuously enrolled in insurance plans, who had been prescribed an SGLT2 inhibitor at least once, and who did not have advanced kidney disease.

Overall, only 8.7% of these patients with type 2 diabetes filled a prescription for one of the novel drugs, but the use of these agents increased from 3.8% of patients in 2015 to 11.9% of patients in 2019.

Compared to other patients, those who received an SGLT2 inhibitor were younger (median age, 58 years vs 68 years) and were more likely to be male (57% vs 48%) and White (60% vs 57%) or Latinx (16% vs 15%) rather than Asian (4.4% vs 4.8%) or Black (10.8% vs 11.9%). They were also more likely to have an annual household income >$50,000.

Those who received an SGLT2 inhibitor were also more likely to have commercial health insurance rather than Medicare Advantage health insurance.

One of the strongest predictors of receiving this therapy was the patients' having seen an endocrinologist during the past year.

After multivariable adjustment, being Black or Asian, rather than White, was associated with a lower likelihood of being prescribed an SGLT2 inhibitor (odds ratio [OR], 0.83 and 0.94, respectively).

Being female rather than male was also associated with a lower likelihood of being prescribed a drug in this class (OR, 0.84).

Compared to having an annual household income <$50,000, having an annual household income of $50,000 to $100,000 or >$100,000 was associated with increased odds of receiving an SGLT2 inhibitor (OR, 1.05 and 1.08, respectively).

The results were similar among patients with HFrEF, ASCVD, and CKD.

Are SGLT2 Inhibitors Too Expensive? Need to Break Barriers to Access

One reason for these disparities is that these medications are unaffordable for many patients who would receive clinical benefit, the researchers write.

In 2019, the median retail price for a 30-day supply of an SGLT2 inhibitor was $300 (interquartile range, $285 – $303). The estimated annual out-of-pocket costs ranged from $1097 to $1211, the authors note. By contrast, therapies such as sulfonylureas can be obtained through $4 generic drug programs at certain pharmacies.

Another reason for the disparities could be that "the demonstrated clinical benefit [of these agents], dating from 2015, may not yet be common knowledge among many nonspecialist providers who treat patients with diabetes," the researchers note.

To remedy this, the authors stress the need for "further investigation of barriers to accessing this therapy and implementation of strategies to address structural racism and ensure more equitable use of this therapy among Black patients are essential."

There is also a need to make all providers more comfortable prescribing SGLT2 inhibitors and for "strategies, such as decision pathways, for new guidelines in order to lessen [gender] inequities by reducing subjectivity in making the decision to initiate therapy," they write.

"Given the demonstrated cost-effectiveness of these medications, our results suggest that out-of-pocket costs should be minimized," Eberly and colleagues urge.

Eberly and Adusumalli have disclosed no relevant financial relationships. Disclosures of the other authors are listed with the original article.

JAMA Netw Open. Published online April 15, 2021. Full text.

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