Associate Professor Pharmacoepidemiology ETH Zurich, Switzerland, Switzerland
Background: Since 2018, the UK’s National Institute for Health and Care Excellence (NICE) recommends sodium-glucose cotransporter-2 inhibitors (SGLT-2is) as second-line therapy following metformin for individuals with type 2 diabetes (T2D), particularly when at high cardiovascular disease (CVD) risk, while GLP-1 receptor agonists (GLP-1RAs) are reserved for those in whom triple therapy has failed. In contrast, the American Diabetes Association recommends both treatments as second- or third-line therapies. The impact of NICE's T2D guidelines on treatment trajectories for patients initiating GLP-1RA therapy is unclear.
Objectives: To describe real-world utilization trajectories of glucose-lowering therapies prior to initiating GLP-1RA therapy in UK primary care, stratified by CVD history and calendar time, to identify if UK prescribing patterns of GLP-1RAs align with NICE guidelines.
Methods: Using the IQVIA Medical Research Data (IMRD) incorporating data from THIN, A Cegedim Database, we included adults with T2D initiating GLP-1RA therapy in UK primary care between 01-Jan-2007 and 30-Jun-2023. We described treatment trajectories from the first glucose-lowering therapy up to GLP-1RA initiation, stratified by CVD history and calendar time (GLP-1RA initiation pre- or post-01-Jan-2018).
Results: We included 29,780 individuals initiating GLP-1RA therapy, with 62.2% (n=18,517) initiating before and 37.8% (n=11,263) after 2018. Before 2018, liraglutide (47.4%) and exenatide (41.4%) were the most initiated GLP-1RAs, while semaglutide (45.1%) and dulaglutide (41.4%) dominated after. Most GLP-1RA initiators (63.5%) received their first GLP-1RA as fourth-line (35.4%) or later-stage therapy (28.1%), with only 0.7%, 10.5%, and 25.3% initiating GLP-1RAs as first-line, second-line, or third-line therapy, respectively, being consistent pre- and post-2018. The utilization patterns of glucose-lowering therapies shifted over time, with SGLT-2i use prior to GLP-1RA initiation increasing from 6.8% before 2018 to 60.6% after, while being not preferentially prescribed among individuals with a CVD history. In the post-2018 cohort, 50.8% used SGLT-2is concomitantly at GLP-1RA initiation, indicating GLP-1RAs were predominantly added to SGLT-2is rather than replacing them.
Conclusions: In line with NICE guidelines, GLP-1RAs were mostly initiated in later therapy stages across UK primary care, following the use of at least three other glucose-lowering therapies. Post-2018, most individuals received SGLT-2is concomitantly at GLP-1RA initiation, while CVD history did not influence therapy patterns, highlighting opportunities for optimizing care in individuals with T2D at high CVD risk.
