2024 Eastern States Conference

TITLE:
Evaluation of sodium glucose co-transporter 2 inhibitor prescribing practices in Veterans with type 2 diabetes mellitus and atherosclerotic cardiovascular disease 

AUTHORS:
Rose Sebastian BA, PharmD, Jessica Pyhtila PharmD, BCPS, BCGP, Veterans Affairs Maryland Health Care System, Baltimore, Maryland 

OBJECTIVE:
Characterize sodium glucose co-transporter 2 inhibitor (SGLT2I) prescribing practices in the context of renal function, age, and clinic follow up 

SELF ASSESSMENT QUESTION:
What other reasons, besides those in this study, may affect SGTL2I prescribing for patients with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease (ASCVD)?

BACKGROUND:
The primary objective of this study is to characterize renal function, age, and clinic follow up among Veterans with T2DM and ASCVD without a SGLT2I prescription from July 2023 to October 2023. The secondary objective of this study is to describe providers and services within the Veterans Affairs Maryland Health Care System (VAMHCS) that are prescribing SGLT2Is for Veterans with T2DM and ASCVD from July 2023 to October 2023. 

METHODOLOGY:
The primary outcome of this retrospective cohort study is to determine the percentage of Veterans with T2DM and ASCVD not prescribed a SGLT2I based on  age, renal function, and clinic follow up. The secondary outcome of this study is to determine the percentage of providers and services prescribing SGLT2Is for Veterans with T2DM and ASCVD. Inclusion criteria: Veterans 18 years of age and older with a diagnosis of T2DM and ASCVD (acute coronary syndrome/myocardial infarction stable/unstable angina, cerebrovascular disease, coronary artery disease with/without revascularization, arterial revascularization, or peripheral arterial disease of atherosclerotic origin) and assigned to a primary care team during July 2023 through October 2023. Exclusion criteria: Active SGLT2I prescription at any time during the study period, type 1 diabetes mellitus, latent autoimmune diabetes in adults, pancreatic insufficiency, history of ketosis, history of alcohol abuse or dependence, hypersensitivity reaction/allergy to SGLT2Is, severe renal impairment (eGFR <30 mL/min/SA), presence of genitourinary risk factors, and discontinued prescription for a SGLT2I at anytime during the study period or 6 months prior. 

RESULTS:
A total of 3808 Veterans were identified with T2DM and ASCVD based on ICD-10 codes from July 2023 to October 2023 . From the 3808 Veterans, 260 Veterans were screened based on inclusion and exclusion criteria. Of the 260 Veterans, 114 Veterans were included in the study. 91% of Veterans with T2DM and ASCVD not prescribed a SGLT2I were 65 years of age and older. 73% of Veterans with T2DM and ASCVD without a SGLT2I prescription had eGFRs of 60 mL/min/SA and greater. 55% of Veterans with T2DM and ASCVD not prescribed a SGLT2I had clinic follow up. 

A total of 41 Veterans had active SGLT2I prescriptions from July 2023 to October 2023. Among providers, 65.8% of SGLT2Is prescribed were by physicians followed by clinical pharmacist practitioners (17%), nurse practitioners (9.7%), physician's assistants (2.4%), and attendings from cardiology and endocrinology (2.4% each). Among types of services, 39% of SGTL2Is prescribed were by providers within the primary care setting followed by ambulatory care/emergency care (24.3%), pharmacy (19.5%), medical (14.6%), and geriatrics/extended care (2.4%). 

CONCLUSIONS:
Veterans with T2DM and ASCVD without a SGTL2I prescription were ≥65 years old and eGFRs ≥60 mL/min/SA , which is consistent with other trials that have evaluated a similar objective. Veterans with T2DM and ASCVD without a SGLT2I prescription had clinic follow up which is inconsistent with other trials that have evaluated a similar objective. Physicians and those within the primary care setting prescribed SGLT2Is more often compared to other providers and services. Providers may benefit from the addition of a clinical reminder within the electronic health record coupled with educational materials on how to utilize the existing academic detailing dashboard to alert them to Veterans with T2DM and ASCVD without a SGLT2I prescription.