SGLT2 Inhibitor Use Stunted for Black, Female, Lower Income Type 2 Diabetes Patients

In a recent study released by JAMA, it was found there’s a significance between race, gender, and socioeconomic status and the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors among patients with type 2 diabetes in the United States.

It was discovered in that in a study conducted from 2015 to 2019 of over 900,000 type 2 diabetes patients commercially insured and under Medicare Advantage, the use of SGLT2 inhibitors increased. However, the use remained low among patients with heart failure and kidney and cardiovascular disease. Black race, females and lower household income patients were associated with the lower inhibitor rates.

These results mean there are factors of social determinants of health (SDoH) present in SGLT2 treatment and if they aren’t addressed correctly, disparities among kidney and cardiovascular patients may worsen in the U.S.

This is an issue because SGLT2 inhibitors significantly reduce deaths from cardiovascular conditions, hospitalizations for heart failure, and progression of kidney disease among patients with type 2 diabetes. According to the study, Black individuals have an unreasonable burden of cardiovascular and chronic kidney disease; all while adoption of novel therapeutics for this group, for female, and low socioeconomic status patients have been slower compared to White, male, or higher economic status patients.

Of patients 18 and older, 8.7% of those recorded in the study received inhibitor treatment during that time period while 91.3% did not.

Patients - typically Black, female and of low-income households – were shown to have these limitations to this novel treatment due to a number of barriers. These barriers include decreased access to quality diabetes care and to specialists familiar with the benefits of SGLT2 inhibitor use, structural racism, provider bias that certain groups of patients may be less likely to be adherent to treatment with an expensive agent, and prescription abandonment owing to economic barriers, according to the study.

Additionally, it’s been found in prior studies lower rates of SGLT2 inhibitor prescription continued even after adjustment for visits to cardiology and endocrinology specialists. This result suggests that racism and bias in care delivery may contribute to the findings of this study as well.

Given the increasing amount of evidence supporting the clinical benefit of SGLT2 inhibitor treatment, further investigation of barriers to accessing this therapy and the implementation of strategies to address racism and ensure more equitable use of this therapy among Black patients are essential.

Data in the study for inequities toward Latinx patients were not present in SGLT2 inhibitor use, however, Asian race was associated with a lower rate of SGLT2 inhibitor use. Although, for Asian patients who have access to care, provider interactions are more frequently characterized by lower rates of patient-centered care and input regarding treatment decisions, which may explain the results.

Gender Inequalities

In addition to racial inequities in SGLT2 inhibitor use, other structural inequities were discovered based on gender and socioeconomic status. Among patients with type 2 diabetes, females were less likely to be prescribed an SGLT2 inhibitor, even among those with heart failure, cardiovascular and kidney disease. This is consistent with findings from prior studies of female patients in where therapies were initially adopted more slowly and underused among female patients. Poor provider communication may also contribute to gender inequity.

Socioeconomic Status Inequalities

Those with a median household income of greater than or equal to $100,000 were 8% more likely and those with a median income ranging from $50,000 to $99,999 were 5% more likely to receive SGLT2 inhibitor therapy than were those with a median income of less than $50,000.

Affordability and out-of-pocket costs of these agents may be excessive, leading to prescription abandonment, especially compared with the cost of older, more traditionally used therapies. Despite SGLT2 inhibitor coverage being relatively high in 2019 for Medicare beneficiaries, median retail prices for a 30-day supply were $300. Estimated annual out-of-pocket costs ranged from $1,097 to $1,211.

Commercial insurance was one of the factors most strongly associated with SGLT2 inhibitor prescription in the study, suggesting sufficient coverage and medication cost may be associated with different rates of use. Given the cost- effectiveness of these medications, the results suggest out-of-pocket costs should be minimized. In addition, provider biases about the ability of patients with lower socioeconomic status to afford and adhere to treatment with an SGLT2 inhibitor may contribute to differential prescribing patterns.

Lastly, it was found in the study having a visit with an endocrinologist in the past 12 months was one of the strongest factors positively associated with SGLT2 inhibitor use. The demonstrated clinical benefit may not yet be common knowledge among many providers who treat patients with diabetes. Strategies to increase the comfort of all providers with prescribing SGLT2 inhibitor therapy will be essential to address inequitable use and ensure improved cardiovascular and kidney outcomes for all patients with type 2 diabetes.