Pharmacoepidemiology
Prescribing preferences for Antidiabetic Medications among older Type 2 Diabetes (T2D) patients with Alzheimer’s Disease (ADRD) and multimorbidity, 2013-2019 Julia Liaw* Julia Liaw Chintan Dave
Older adults with T2D face high levels of multimorbidity burden and are more likely to be diagnosed with ADRD. In recent years, >20 new medications have been approved for managing T2D making significant strides on morbidity and mortality outcomes; however, there is paucity of data evaluating the trends in their uptake by multimorbidity levels and ADRD status.
We used Medicare fee-for-service (2013-2019) data to identify a cohort of older T2D patients newly initiating the following second-line antidiabetic medications: glucagon-like peptide-1 receptor agonist (GLP-1RA), sodium-glucose cotransporter-2 inhibitor (SGLT2i), dipeptidyl peptidase-4 inhibitor (DPP4i), sulfonylurea (SU), thiazolidinedione. Initiation trends were analyzed based on ADRD presence and by severity of multimorbidity.
Among 1,788,762 T2D patients, SU initiations declined significantly by 24.4% from 50.3% in 2013 to 25.8% in 2019, replaced largely with SGLT2i initiations which increased by 20.8% (1.3% to 22.0%); these trends were less pronounced among patients with ADRD (n=180,512) versus those without (n=1,549,100). By 2019, individuals with ADRD favored DPP4i as the most initiated medication, with a 13.3% higher initiation rate compared to those without ADRD (34.3% vs. 21.0%). Consequently, they were less likely to initiate SGLT2i and GLP-1RA by 8.0% (14.4% vs. 22.4%) and 5.9% (17.1% vs. 23.0%), respectively. Higher multimorbidity correlated with increased DPP4 inhibitor utilization and decreased SGLT2 inhibitor utilization.
Initiation of newer T2D agents increased regardless of ADRD presence, but with diminished likelihood in severe multimorbidity. This reduced adoption may stem from unique clinical challenges (e.g., distinctive adverse reactions) and high cost in a medically complex population, and limited evidence in older, multimorbid patients due to trial exclusion or underrepresentation, warranting further investigation in multimorbidity and its impact on prescribing.