Effects of Reimbursement Policy Change on Utilization of Injectable Semaglutide for Type 2 Diabetes and on Glycemic Control Among Discontinuers: A Danish Nationwide Cohort Study

Objectives To evaluate the impact of reimbursement restrictions for glucagon-like peptide-1 receptor agonists (GLP-1RAs) for type 2 diabetes, introduced in Denmark in November 2024, on injectable semaglutide (Ozempic®) utilization patterns and subsequent HbA1c changes among discontinuers. Design Nationwide registry-based cohort study. Setting Denmark. Participants Adults treated with injectable semaglutide for diabetes (January 2018 to December 2025). Main outcome measures We described temporal patterns in injectable semaglutide use before and after the policy change. Among semaglutide continuers after the policy change, we assessed whether continuation met a key criterion in the new policy: non-feasibility of sodium-glucose cotransporter 2 inhibitor use and high cardiovascular risk. We characterized semaglutide discontinuers around the policy implementation (March 2024 to November 2024) and subsequent treatment switches. Among discontinuers, we evaluated HbA1c changes and performed interrupted time series (ITS) analyses. Results Following the policy change, use of injectable semaglutide declined modestly before subsequently increasing. Among 61,120 individuals classified as semaglutide continuers, 27,143 (44%) were already using an SGLT2i. Of the remaining 33,977 (56%), only 1,862 (5.5%) met a key reimbursement criterion (i.e., non-feasibility of SGLT2i use and high cardiovascular risk). Among 79,305 individuals with a semaglutide fill between March 2024 and November 2024, 22,096 (28%) were classified as discontinuers. Within six months, ∼40% of discontinuers switched to other glucose-lowering therapies, most commonly SGLT2is (24%). 37% of discontinuers later reinitiated semaglutide. Among individuals with an on-treatment HbA1c measurement (within 12 months before their last semaglutide fill) and an off-treatment HbA1c measurement (6-12 months after their last semaglutide fill) (n=13,017), mean HbA1c increased from 49 to 57 mmol/mol (mean change +7.4 mmol/mol, 95% CI 7.2-7.6). ITS analysis showed that HbA1c increased by 5.9 mmol/mol (95% CI 5.1-6.7) at six months post-discontinuation, which attenuated to 3.1 mmol/mol (95% CI 2.2-4.1) at 12 months; raw monthly means (not included in the ITS model) suggested this persisted through 18 months. Conclusions Following the policy change, population-level use of injectable semaglutide declined modestly before increasing again. Most discontinuers did not initiate another glucose-lowering therapy and experienced an increase in HbA1c that did not fully return to pre-discontinuation levels during follow-up. What is already known on this topic The rapid uptake and high costs of GLP-1 receptor agonists, including injectable semaglutide for diabetes (Ozempic®), have prompted health systems to consider how access to these treatments should be prioritized and reimbursed. Little is known about how reimbursement restrictions on GLP-1 receptor agonists influence treatment patterns and glycemic control after treatment discontinuation. What this study adds Following a national reimbursement restriction in Denmark, more than one in four patients discontinued injectable semaglutide for diabetes, and among those who switched treatment, SGLT2 inhibitors were the most common alternative, while most discontinuers did not initiate another glucose-lowering drug within six months. Approximately one in three discontinuers reinitiated their semaglutide therapy more than six months after stopping. Discontinuation of injectable semaglutide for diabetes was followed by a rise in HbA1c that, despite improvement over time, did not return to pre-discontinuation levels over 18 months, highlighting a potential clinical consequence of restricting access to an effective glucose-lowering treatment option.