SGLT2i Prescriptions for Heart Failure Are Rising, but Vary Across US

The use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) to treat patients with heart failure with mildly reduced (HFmrEF) or preserved ejection fraction (HFpEF) has surged since 2021, although substantial disparities remain between hospitals.¹

Published in JAMA Cardiology and based on data from the Get With The Guidelines–Heart Failure (GWTG-HF) registry, the study found that discharge prescriptions of SGLT2is for patients with a left ventricular ejection fraction (LVEF) above 40% rose from 4.2% in mid-2021 to 23.5% by late 2023. This increase comes after findings from the pivotal EMPEROR-Preserved trial demonstrated the drugs' benefits. Yet, adoption rates across the US are far from uniform.²

SGLT2i prescription rates quadrupled for patients with diabetes, jumping from 7.5% to 30.3% in just 2 years. | Image credit: 18percentgrey – stock.adobe.com

Of 158,849 patients hospitalized for heart failure at 557 US hospitals, only 13.9% were prescribed an SGLT2i at discharge, with a median (IQR) prescription rate of 10.9% (7.0%-17.6%).¹ The data revealed significant hospital-level variation, with a median OR of 2.12, indicating that a patient’s chance of receiving an SGLT2i could more than double depending on the hospital.

“This variation highlights the need to understand the strategies used by higher prescribing centers to increase SGLT2i adoption,” the authors said.

Interestingly, patients with mildly reduced LVEF (41%-49%) were more likely to be prescribed an SGLT2i than those with preserved LVEF (≥ 50%), with prescription rates of 18.5% vs 13%, respectively. SGLT2i use was also more common among patients with Medicaid insurance and atrial fibrillation, and less common among patients with kidney failure or anemia.

The analysis also identified disparities related to demographics: younger patients, those with type 2 diabetes (T2D), and individuals of Black, Hispanic, or “other” non-White races were more likely to receive these drugs compared with their counterparts. Specifically, among patients with T2D, SGLT2i prescription rates quadrupled from 7.5% to 30.3% in just 2 years.

However, some troubling trends emerged, including that women were less likely than men to be prescribed SGLT2is.

“These differences may stem from clinician hesitance to prescribe SGLT2is due to concerns about urogenital infection risks, as well as patients’ perceptions of increased adverse reactions,” the authors suggested.

Additionally, of the 518 hospitals with at least 10 eligible discharges, only 11 of them prescribed SGLT2is to more than half of their patients. In contrast, nearly 45% of hospitals discharged fewer than 10% of eligible patients with an SGLT2i prescription.

“Implementation strategies, such as education, electronic alerts, and performance feedback, may help increase prescription rates,” the authors said. “National initiatives, such as GWTG-HF registry quality measures, may be a strategy to increase adoption across US hospitals.

Although the study highlighted the rapid uptake of SGLT2is, the authors also noted key limitations, including that they did not have data on medication adherence or prescription fills post discharge, nor could they determine whether a cardiology team was involved in the care of all patients. Additionally, while the analysis tracked prescription trends, it did not evaluate the impact of SGLT2i use on long-term outcomes like mortality or rehospitalization.

References

1. Abdeljawad M, Spertus JA, Ikeaba U, et al. Early adoption of sodium-glucose cotransporter-2 inhibitor in patients hospitalized with heart failure with mildly reduced or preserved ejection fraction. JAMA Cardiol. Published online November 18, 2024. doi:10.1001/jamacardio.2024.4489

2. Caffrey M. EMPEROR-Preserved first trial to show positive results in HFpEF. AJMC®. July 7, 2021. Accessed November 14, 2024. https://www.ajmc.com/view/emperor-preserved-first-trial-to-show-positive-results-in-hfpef