Study: Use of Glucose-Lowering Agents with Cardiovascular Benefit Vary Among Medicaid Patients

The relative use of glucose-lowering agents with cardiovascular benefits among patients with type 2 diabetes (T2D) vary across states, according to a report published in JAMA Network Open. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP1RA) showed evidence of cardiovascular benefits.

“We found considerable variation among states in the relative use of SGLT2i and GLP1RA and their rates of increase…and whether this use varies across states, given wide variations in state populations and the support provided to different state Medicaid programs,” the study authors wrote.

Patient preference, familiarity with the physician, and other Medicaid policies may contribute to the varied results. Although cost-sharing or prior authorization were not studied in this analysis, they may be associated with the overall varied drug use, according to the investigators.

The primary cause of mortality in patients with T2D is cardiovascular death, and glucose-lowering agents may lower this risk. Metformin is a traditional glucose-lowering drug that is prescribed to patients. Insulin would then be given if this treatment does not decrease hyperglycemia.

However, there are scaling up pharmacologic (and glucose-lowering) treatments that patients can take before being prescribed insulin. Scaling-up treatments can be nonmetformin, noninsulin glucose-lowering drugs such as SGLT2i and GLP1RA, which “have demonstrated reductions in cardiovascular mortality,” the study authors wrote.

Researchers evaluated the rate of prescriptions of glucose-lowering agents with established cardiovascular benefits in Medicaid patients, who are generally low-income with disproportionality high rates of diabetes. This population also tends to have more severe cardiovascular outcomes.

In this cross-sectional study, nonmetformin, noninsulin glucose-lowering drugs were divided into 3 cohorts: SGLT2i, GLP1RA, and all other classes of glucose-lowering drugs. Researchers analyzed use data over 5 years, accounting for cardiovascular benefit, geography, and changes in use over time by Medicaid patients.

The data showed that Medicaid patients in managed care organizations that spent more per enrollee had a higher use ratio of glucose-lowering agents with cardiovascular benefits, on average. These programs either may cover the higher cost drugs and/or new drugs with known benefits, including SGLT2i and GLP1RA.

However, “states that more often contracted with managed care organizations had lower use ratios,” the study authors wrote. These organizations “tend to encourage the use of lower-cost drugs, such as generics and drugs which have a negotiated supplemental rebate.”

Other factors that may impact the frequency of these drugs among Medicaid patients include drug coverage, formulary placement, and prescribing restrictions. For example, Wyoming only requires patients take metformin for 90 days before starting an SGLT2i or GLP1RA.

A study limitation was assuming Medicaid patients dosed the same way. Additionally, researchers could not establish a causal relationship, and several T2D statistics were not specific to Medicaid patients. Finally, it was not determined whether higher doses of SGLT2i and GLP1RA improved mortality, nor what the appropriate dosage level should be.

Current guidelines recommend SGLT2i and GLP1RA therapy for T2D patients. However, in 2018, only 1 in every 5 T2D patients was prescribed SGLT2i.

“States with substantially lower relative use should determine whether some of their Medicaid enrollees are, in fact, receiving suboptimal diabetes care and examine their Medicaid policies to determine which factors may be contributing to this result,” the study authors wrote.

Reference

Zhai, Mike, Avorn, Jerry, Liu, Jun, et al. Variations in Use of Diabetes Drugs With Cardiovascular Benefits Among Medicaid Patients. JAMA Netw Open. 2022;5(11):e2240117. doi:10.1001/jamanetworkopen.2022.40117