Trends in First-Line Glucose-Lowering Drug Use in Adults With Type 2 Diabetes in Light of Emerging Evidence for SGLT-2i and GLP-1RA

Objective: We evaluated recent utilization trends and predictors of first-line antidiabetic treatment in patients with type 2 diabetes.

Research Design and Methods: Using two large U.S. health insurance databases (Clinformatics and Medicare), we identified adult type 2 diabetes patients who initiated antidiabetic treatment from 2013 through 2019. Quarterly trends in use of first-line antidiabetic treatment were plotted overall and stratified by cardiovascular disease (CVD). Multinomial logistic regressions were fit to estimate predictors of first-line antidiabetic treatment, using metformin, the recommended first-line treatment for type 2 diabetes, as the common referent.

Results: Metformin was the most frequently initiated medication used by 80.6% of Medicare beneficiaries and 83.1% of commercially insured patients. Sulfonylureas were used by 8.7% (Medicare) and 4.7% (commercial). Both populations had low use of sodium-glucose cotransporter 2 inhibitors (SGLT-2i, 0.8% [Medicare] and 1.7% [commercial]) and glucagon-like peptide 1 receptor agonists (GLP-1RA, 1.0% [Medicare] and 3.5% [commercial]), with increasing trends over time (P < 0.01). Initiators of antidiabetic drugs with established cardiovascular benefits (SGLT-2i and GLP-1RA) were more likely to be younger, and had prevalent CVD or higher socioeconomic status compared with initiators of metformin.

Conclusions: Among adult patients with type 2 diabetes, metformin was by far the most frequent first-line treatment. While the use of SGLT-2i and GLP-1RA was low from 2013 through 2019, it increased among patients with CVD.