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Fewer than 10% of eligible U.S. patients with type 2 diabetes used a GLP-1 receptor agonist or SGLT2 inhibitor, according to nationally representative data.

While it was estimated that 22.4 million U.S. adults with diagnosed type 2 diabetes met the recommended criteria from the American Diabetes Association and the European Association for the Study of Diabetes to use these medications, only 3.7% used GLP-1 receptor agonists, 5.3% used SGLT2 inhibitors, and 9.1% used either from 2017 to 2020, reported Shichao Tang, PhD, of the CDC's Division of Diabetes Translation in Atlanta, and colleagues.

Of note, 12.1% of patients who didn't meet eligibility for these drugs were prescribed one. This was more common for GLP-1 receptor agonists (7.2%) than SGLT2 inhibitors (4.9%), Tang and team noted in their brief research report published in the .

"It's important for primary care providers to be aware that many of their patients with type 2 diabetes may qualify for these medications," Tang told MedPage Today.

He added that while these results weren't necessarily surprising, they were insightful, particularly in regards to the findings on eligibility.

Why are so few eligible patients using these medications? It's potentially due to their "substantially" higher cost, the researchers suggested.

In a 2019 review of cost-effectiveness analyses published in , GLP-1 receptor agonists and SGLT2 inhibitors were deemed cost-effective when prescribed as second-line agents compared with insulin or sulfonylureas.

However, a 2022 cost-effectiveness study, also published in the Annals of Internal Medicine, found SGLT2 inhibitors and GLP-1 receptor agonists were not cost-effective when used as first-line agents compared with traditional first-line metformin, with first-line SGLT2 inhibitors and GLP-1 receptor agonists estimated to cost $43,000 and $49,000 more over a lifetime, respectively, compared with metformin.

In order to be considered cost-effective as first-line agents, both drugs would have to cut their price tag by 70%, even with their cardiovascular advantages.

"It's important to note that the most recent data available to study was during a period when these two medications were not recommended as first-line treatment to many patients now eligible in the 2022 guidelines, though they were offered as second-line treatment to some patients," Tang said.

In the updated , the American Diabetes Association and European Association for the Study of Diabetes advised patients with type 2 diabetes who have established or are at high risk for atherosclerotic cardiovascular disease (ASCVD) to use a GLP-1 receptor agonist, while those with comorbid established ASCVD, chronic kidney disease, or heart failure or who are at high risk for ASCVD are advised to use an SGLT2 inhibitor.

"Cost-effectiveness was not formally considered in the current guideline," the researchers noted. Tang added that "more research is needed to evaluate the cost-effectiveness of these drugs and to determine exactly why these numbers are low."

"It's also important to continue research since the change in recommendations," he said. "Newer data, when available, may help us observe if and how the new recommendations affect usage of these therapeutics."

For their estimates, the researchers included nonpregnant adults ages 20 years and older from the National Health and Nutrition Examination Survey who self-reported having diabetes. Those with type 1 diabetes and those currently using insulin were excluded.

Based upon the 2022 consensus report, 46% of patients met the recommended criteria for treatment with a GLP-1 receptor agonist and 82.3% met the criteria for treatment with an SGLT2 inhibitor.

When stratified by clinical factors, 100% of patients with ASCVD or at high ASCVD risk, heart failure, or chronic kidney disease were eligible for one of these drugs. Looking at diabetes duration, about 73% of patients who had diabetes for 5 years or less met the eligibility criteria, which jumped to 84.6% for those with a duration of 6-10 years, and 87.5% for those who had diabetes for 11 or more years. About the same proportion of patients who met or who were below the BMI threshold also met the criteria.

According to sociodemographic factors, a higher proportion of men met the recommended criteria for an SGLT2 inhibitor or a GLP-1 receptor agonist compared with women (84.6% vs 79.5%), as did those who were 65 and older compared with those younger than 65 (97% vs 70%) and those who were white versus non-white (83.6% vs 80.5%).

When stratified by health insurance, nearly all patients on Medicare were eligible for one of these agents (94.5%), although many with Medicaid (77.5%), other or no insurance (74.8%), and private insurance (65.4%) also qualified.

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