SGLT2 Inhibitor Fills Rose in Guideline-Targeted Patients After 2019 ADA Update

Sodium-glucose cotransporter 2 inhibitor (SGLT2i) fills rose more among guideline-targeted than nontargeted Medicare beneficiaries with type 2 diabetes after the 2019 American Diabetes Association (ADA) guideline update, according to a serial cross-sectional study in JAMA Network Open. Gains were larger among patients of endocrinologists who later scored higher on a board knowledge assessment.

The 2019 ADA Standards of Care recommended SGLT2is for patients with atherosclerotic cardiovascular disease (ASCVD), heart failure, or chronic kidney disease (CKD) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for those with ASCVD or CKD. Investigators compared prescribing before and after the update and by endocrinologists’ first-year scores on the American Board of Internal Medicine (ABIM) Longitudinal Knowledge Assessment (LKA).

The study used 2017 to 2022 traditional Medicare claims for 177,284 beneficiaries treated by 1061 endocrinologists who first enrolled in the LKA in 2022 to 2023. Targeted patients had CKD or heart failure in the SGLT2i analysis and CKD or ASCVD in the GLP-1 RA analysis. Relative to 2018, the adjusted SGLT2i fill-rate gap between targeted and nontargeted patients widened each year, reaching 11.4 percentage points in 2022 (95% CI, 10.5-12.3). Adjusted SGLT2i fill rates among targeted patients rose from 8.9% in 2018 to 30.1% in 2022. The GLP-1 RA gap was smaller, at 2.4 percentage points.

For SGLT2is, the 2022 gap was 3.9 percentage points larger (95% CI, 1.4-6.5) among patients of endocrinologists in the top vs bottom LKA score quartile. Middle-quartile differences were generally smaller and imprecise, and GLP-1 RA differences across quartiles were small, with wide confidence intervals.

The authors noted that the design precludes causal inference, that several prominent randomized trials were published soon after the update, and that GLP-1 RA shortages emerged late in the study period. Results may not generalize beyond older fee-for-service beneficiaries with Part D coverage or to endocrinologists outside the voluntary LKA.

Source: Gray BM, Vandergrift J, Landon BE, McCoy R. Prescribing SGLTis and GLP-1 RAs for patients with type 2 diabetes, guideline updates, and Longitudinal Knowledge Assessment scores. JAMA Netw Open. 2026;9(10):e2640858. doi:10.1001/jamanetworkopen.2026.40858