Prescription Patterns of Cardiovascular and Kidney Protective Therapies Among Patients with Type 2 Diabetes and Chronic Kidney Disease

  

Objective

To assess the prevalence and correlates of prescription of sodium-glucose co-transporter-2-inhibitors (SGLT2i) and/or glucagon-like peptide-1-receptor agonists (GLP1-RA) in persons with type 2 diabetes mellitus (T2DM) with and without chronic kidney disease (CKD). 

Methods

Cross-sectional analyses of SGLT2i and GLP1-RA prescriptions from January 1st, 2019, to December 31st, 2020, in the Veterans Health Administration System. The likelihood of prescriptions was examined by presence or absence of CKD and by predicted risks of atherosclerotic cardiovascular disease (ASCVD) and end-stage kidney disease (ESKD). 

Results

Of 1,197,880 adults with T2DM, SGLT2is and GLP1-RAs were prescribed to 11% and 8% of patients overall, and to 12% and 10% of those with concomitant CKD, respectively. In adjusted models, patients with severe albuminuria were less likely to be prescribed SGLT2i or GLP1-RA versus non-albuminuric patients with CKD: OR (95% CI) = 0.91 (0.89, 0.93) and 0.97 (0.94, 1.00), respectively. Patients with 10-year ASCVD risk >20% (versus <5%), had lower odds of SGLT2i use (OR=0.55 (0.52, 0.59)) and GLP1-RA prescription (OR=0.54 (0.50, 0.59)). A 5-year ESKD risk >5%, compared with <1%, were associated with lower likelihood of SGLT2i prescription (OR=0.63 (0.59, 0.67)) but higher likelihood of GLP1-RA prescription (OR=1.53 (1.46, 1.61)).

Conclusions

Among a large cohort of patients with T2DM, prescription of SGLT2i and GLP1-RA was low in those with CKD. We observed a “risk-treatment paradox”, whereby patients with higher risk of adverse outcomes were less likely to receive these therapies.