PMDA e-News - February 2024

February 2024

GLP-1 Agonists

By Shauna Assadzandi, MD, Clinical Assistant Professor, University of Pittsburgh

The world of medication treatment for diabetes is constantly changing. The introduction of GLP-1 agonists, like Ozempic and Trulicity, have changed the guidelines for treatment in Type-2 Diabetics (T2DM) and are quickly becoming preferred agents. Given their benefits not only in improving glycemic indexes, but also in weight loss and improved cardiovascular outcomes, this is not surprising. While Metformin is still the first indicated drug for T2DM, the second line is now SGLT-2 inhibitors or GLP-1 Agonists. GLP-1 agonists are also now being recommended for heart disease patients as well. However, the data for these medications in the geriatric population, especially patients over the age of 75 has been limited. The outcomes of these medications are bound to change in patients who are frail, have chronic illness, and protein-calorie malnutrition issues.

A systemic review of GLP-1 agonists in patients aged 65 and up showed improvement in cardiovascular mortality, stroke, and myocardial infarction. These outcomes seem to translate to patients over the age of 75 as well, but there is very limited data available for patients in that age range.¹ As these patients are underrepresented in these studies, we have little data on side effects and poor outcomes in this population. Some cardiovascular studies have shown improvement in overall risk in frail patients, but those studies are also only in small groups.

As a clinician routinely prescribing these medications, I have a few concerns. The first is the weight loss component with these medications. For some patients, this can be very helpful. The weight loss can improve their glucoses, movement, and function. For other patients, further weight loss can lead to orthostasis and worsening malnutrition. Secondly, I’ve had patients struggle a lot with the gastrointestinal side effects. The nausea and constipation have worsened pre-existing issues in this area and have made further medication changes necessary.

Finally, the cost and coverage by Medicare has created difficulty obtaining these medications and continuing them. One analysis showed that even with Medicare coverage the average out of pocket costs for a GLP-1 agonist was greater than $1500.² There are some assistance programs, but they are few and far between. Coverage by Medicare A in post-acute care is going to provide so much coverage, but there have been no studies aimed at the cost to the facility for these medications. In long-term care this same issue is going to persist. The cost will be to the patient themselves and is going to be a barrier to remaining on these medications.

For now, the path forward with these medications is going to require risk vs. benefit conversations with patients and continued insurance and cost battles. More studies aimed at GLP-1 agonists use in patients over the age of 75 and patients with Medicare coverage are needed.

References:

1. Karagiannis T, Tsapas A, Athanasiadou E, Avgerinos L, Liakos A, Matthews D, Bekiari E. GLP-1 receptor agonists and SGLT2 inhibitors for older people with type 2 diabetes: A systematic review and meta-analysis. Diabetes Research and Clinical Practice. 2021; 174. https://doi.org/10.1016/j.diabres.2021.108737.

2. Luo J, Feldman R, Rothenberger SD, Hernandez I, Gellad WF. Coverage, Formulary Restrictions, and Out-of-Pocket Costs for Sodium-Glucose Cotransporter 2 Inhibitors and Glucagon-Like Peptide 1 Receptor Agonists in the Medicare Part D Program. JAMA Netw Open. 2020;3(10):e2020969. doi:10.1001/jamanetworkopen.2020.20969

Any views or opinions presented in this article are solely those of the author and do not necessarily represent any policy or position of PAMED, PMDA, AMDA, its affiliates, and members.

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