Diabetes drugs underused in Australia despite proven benefits, study reveals

Pharma News: A new analysis has revealed that more Australians with type 2 diabetes should have access to potentially lifesaving medicines, particularly those that protect against heart and kidney disease – two of the leading causes of death for people with diabetes.

Researchers from UNSW Sydney have highlighted the need for more widespread use of add-on medicines – SGLT2 inhibitors and GLP-1 receptor agonists – that provide better protection for the heart and kidneys. While about one in three people with type 2 diabetes are currently receiving early treatment with these additional therapies, many more could benefit, according to the study.

The research team analysed dispensing records from a 10% random sample of adults covered by the Pharmaceutical Benefits Scheme (PBS). They found that nearly 39,000 people aged 40 and over were prescribed metformin, the standard first-line treatment for type 2 diabetes, between 2018 and 2020. However, only about a third received any add-on therapy within two years of starting treatment.

“More than one million Australians are living with type 2 diabetes, but it is heart and kidney disease that are major causes of death and poor quality of life for these people,” said Dr Tamara Milder, lead author and endocrinologist at UNSW’s School of Population Health.

“Fortunately, there are diabetes medicines available that can also protect their hearts and kidneys, and potentially save lives, but many people are missing out.”

The July PBAC outcomes indicated that negotiations for broader listing of AstraZeneca and Boehringer Ingelheim’s SGLT2 inhibitors (Forxiga and Jardiance respectively) has hit a financial snag. These therapies are to be used as add-on to metformin in type 2 diabetes mellitus (T2DM) for patients with cardiovascular disease or high cardiovascular risk.

Despite the Australian Evidence-Based Clinical Guidelines for Diabetes endorsing the use of SGLT2 inhibitors in this way, the PBAC has now stipulated that a 15% price reduction must be agreed upon by the pharmaceutical companies before the expanded listing can be implemented without further price reductions or a financial cap.

The UNSW study also noted that some clinicians may be slow to adopt newer medications due to concerns over side effects or comfort with older treatments. The COVID-19 pandemic and international drug shortages since 2022 may also have played a role.

“There has been a major shift [in national and international guidelines] in recent years in how we treat diabetes,” Dr Milder said. “It used to just be about managing people’s sugars, but we know that heart and kidney disease are major drivers of death and poor quality of life for people with diabetes, and we have these two major drug classes that can help protect people with type 2 diabetes.”

The SGLT2 inhibitors and GLP-1 receptor agonists not only improve blood sugar management but also offer additional benefits such as weight loss, lower blood pressure, and a reduced risk of kidney and cardiovascular events.

The benefits of these drugs were first highlighted in the Australian Diabetes Society’s (ADS) Type 2 Diabetes Management Algorithm in 2020 and were recommended in 2022 for adults with type 2 diabetes and cardiovascular disease, multiple cardiovascular risk factors, or kidney disease.

Although the study does not indicate how many people in the sample met the existing PBS criteria, it emphasised that people with diabetes are generally at high risk for cardiovascular events, heart failure, and kidney disease.

“We have these medications with heart and kidney benefits that we can see are not being heavily used in early treatment,” Dr Milder explained.

While overall use of add-on therapies remained low, there was an upward trend in the use of SGLT2 inhibitors and GLP-1 receptor agonists as the first add-on therapies, increasing from 28.8% to 35%, and from 3% to 9.6%, respectively.

The researchers focused on six anti-hyperglycaemic medicine classes in their analysis, and of those prescribed add-on therapy, one-third started on the same day as metformin, while the rest waited a median of eight months.

Dr Michael Falster, senior author and researcher at UNSW’s School of Population Health, noted that while these medicines are increasingly prescribed to people with established cardiovascular disease, they remain underutilised overall.

“It’s challenging. We have new medicines with fantastic capabilities in helping prevent progression for serious health outcomes, but a slow uptake,” he said.

The researchers are calling for more action at the policy level to increase healthcare providers’ knowledge and confidence in prescribing these newer medications. They also stressed the need for further research to better understand the gaps in access for eligible patients.

The government continues to review whether it is cost-effective to expand PBS subsidies for these medicines, though drug shortages remain a concern.

“We must ensure there’s equitable access to these medicines for the people for whom there’s the greatest therapeutic benefit,” Dr Falster said.

Dr Milder added, “We must prioritise early access to these medicines for Australians with type 2 diabetes. By doing so, we can better protect their hearts and kidneys, improving both quality of life and overall health, and saving lives.”

This research was funded by the National Heart Foundation of Australia and National Health and Medical Research Council (NHMRC).

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