Evidence-based SGLT2 inhibitor and GLP-1 receptor agonist use by race in the VA healthcare system

Abstract

Importance

Adoption of novel therapeutics often lags for Black versus non-Hispanic White patients. Seminal clinical trials established the cardiovascular efficacy of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) in patients with type 2 diabetes (T2D) and established atherosclerotic cardiovascular disease. However, it is uncertain whether race influences the evidence-based prescription of these agents.

Objective

To determine whether evidence-based prescription of SGLT2i or GLP-1RA differs by Black versus White race in the Veterans Affairs (VA) healthcare system.

Design, Setting, and Participants

Retrospective cohort study of US Veterans with T2D and angiographically confirmed coronary artery disease (CAD) at 84 VA medical centers over the period 2015–2023. Data from the VA Clinical Assessment, Reporting, and Tracking Program were used to construct cohorts eligible for SGLT2i or GLP-1RA treatment based on eligibility criteria for the seminal Empagliflozin, Cardiovascular Outcomes, and Mortality in T2D (EMPA-REG OUTCOME) or the Liraglutide Effect and Action in Diabetes (LEADER) trial, respectively. Multivariable logistic regression estimated adjusted odds of trial-concordant SGLT2i or GLP-1RA prescription by race.

Exposures

Self-identified race.

Main Outcomes and Measures

SGLT2i or GLP-1RA prescription among those with an evidence-based (trial-concordant) indication.

Results

Of 63,561 Veterans with T2D and CAD, 3527 Black and 18,668 White patients met criteria for trial-concordant SGLT2i treatment and 2020 Black and 10,103 White patients for GLP1-RA treatment. Trial-concordant prescription of both classes increased over time for both races but reached only 42 % for SGLT2i and 15 % for GLP1-RA in 2023. Black versus White race was not associated with evidence-based SGLT2i prescription (adjusted odds ratio [OR] 0.96, 95 % CI 0.89–1.04, P = 0.32). However, Black Veterans were less likely than White to be provided with a trial-concordant GLP1-RA prescription (adjusted OR 0.85, 95 % CI 0.74–0.98, P = 0.025).

Conclusions and Relevance

Among patients with T2D and CAD in the VA healthcare system, evidence-based SGLT2i and GLP1-RA prescription increased over time, but many eligible patients remained untreated. Although SGLT2i prescription did not differ by race, Black versus White Veterans were less likely to receive evidence-based GLP1-RA prescription. Racial disparities in evidence-based cardiovascular drug prescription exist even in a healthcare system with few economic barriers and may be drug class-specific.