Diabetes, Obesity, and Cardiometabolic CARE · Jul 13, 2026
Trends in Diabetes Medications After Metformin in Patients at High Versus Moderate Cardiovascular Risk: The BESTMED Consortium 2014-2022
By Lansang MC, Petito LC, Hegermiller E et al.
OBJECTIVE: To compare nationwide prescription trends in medications (dipeptidyl peptidase 4 inhibitors [DPP-4i], glucagon-like peptide 1 receptor agonists [GLP-1 RAs], sodium-glucose cotransporter 2 inhibitors [SGLT2i], or sulfonylureas [SUs]) after treatment with metformin in patients with type 2 diabetes (T2D) at high versus moderate cardiovascular risk by key sociodemographic and health characteristics. RESEARCH DESIGN AND METHODS: Electronic health records and insurance claims from 2014 to 2022 from 10 health systems and two insurance plans from different U.S. regions were evaluated. Risk-stratified multinomial log-linear models were used to model trends in prescribing patterns, adjusted for sociodemographic variables. RESULTS: A total of 104,474 patients were included (28% at high and 72% at moderate cardiovascular risk). Among those at high cardiovascular risk, DPP-4i (2014 24.0%; 2022 11.0%) and SU (66.4%; 35.7%) prescriptions declined, whereas GLP-1 RA (4.4%; 20.5%) and SGLT2i (5.2%; 32.8%) prescriptions increased. Among those at moderate cardiovascular risk, DPP-4i (23.7%; 11.7%) and SU (63.7%; 31.5%) prescriptions declined, whereas GLP-1 RA (5.7%; 30.0%) and SGLT2i (6.9%; 26.8%) prescriptions increased. Annual increases differed by high versus moderate cardiovascular risk for GLP-1 RAs (+2.5% vs. +3.6%/year; P < 0.001) and SGLT2i (+4.0% vs. +3.0%/year; P < 0.001). Greater annual increases in GLP-1 RA prescriptions occurred in women, those aged <65 years, and those with class 2 or 3 obesity, and greater annual increases in SGLT2i prescriptions were seen in men, those aged ≥65 years, and those without class 2 or 3 obesity (all P < 0.01). Greater increases in SGLT2i prescriptions occurred among Black patients, and greater increases in GLP-1 RA prescriptions occurred among those of Hispanic ethnicity at moderate cardiovascular risk. CONCLUSIONS: Prescribing patterns for second-line T2D therapies in those at moderate cardiovascular risk are approaching guideline recommendations for those at high risk. Some trends are potentially clinically explainable, whereas certain racial/ethnic differences may warrant exploration. UNLABELLED: Video 1.Video abstract3e51f820-63ec-4c76-86f4-002f78d7c5f0doc260027video1.