Prescription payment participation associated with GLP-1 RA, adherence to SGLT2i therapy

Utibe R. Essien, MD, MPH

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New research indicates that prescription rewards were independently associated with 12-month adherence to glucagon-like peptide-1 receptor agonist (GLP-1 RA) and sodium glucose cotransporter inhibitor medications 2 (SGLT2i) in patients with type 2 diabetes (T2D) and heart failure.1

Thus, the results suggest that individuals with lower drug payment participation had significantly higher odds of 12-month adherence to GLP-1 RA and SGLT2i therapies, compared to individuals with higher payment participation.

These differences persisted even when controlling for patient demographics, clinical and socioeconomic covariates, demonstrating an independent association of payment amount with adherence to these therapies, wrote the investigation team, led by Utibe R. Essien, MD, MPH, of the Division of General Practice Internal Medicine and Health Services Research at the David Geffen School of Medicine at the University of California, Los Angeles.

The United States is experiencing a steady increase in the prevalence of T2D and heart failure, making modifiable control of risk factors, including physical activity and diet, critical to the management of these diseases. However, prevention of chronic complications additionally requires effective adherence to prescribed medications that have been shown to improve outcomes, including GLP-1 RA and SGLT2is. Trials have shown these drugs have significant reductions in morbidity and mortality for patients with T2D and heart failure, and contemporary guidelines have been updated to reduce the risk of adverse events in these patients.

However, even with their proven benefit, high out-of-pocket costs can be a significant barrier to initiating treatment, and there is little data on how prescription upfront payment might affect long-term adherence to these drugs.2 Accordingly, Essien and colleagues analyzed the association of prescription co-payment with adherence to GLP-1RA and SGLT2i therapies in a nationwide cohort of individuals with T2D and/or heart failure over 12 months.

The retrospective cohort study used de-identified data from the Optum Insights Clinformatics Data Mart database of more than 68 million commercial and Medicare health insurance enrollees. Using drug claims data, the investigators identified all individuals with a new prescription, defined as having no record of a GLP-1 RA or SGLT2i prescription filled in the prior 6 months from January 2014 to September 2020. The primary outcome was l adherence to 12 months of GLP-1 RA or SGLT2i therapies, defined as a proportion of days covered (PDC) of 80% or greater at 1 year.

For the analysis, the independent variable of interest was a 30-day prescription ticket, obtained from pharmacy inquiries and defined as the median at the individual level over 12 months. Investigators classified copayment as low (<$10), medium ($10 to <$50), or high ($50) based on the distribution of copayment data. Multivariate logistic regression models were used to examine the association between payment category and 1-year adherence, adjusting for demographics, medical comorbidities, and socioeconomic factors.

The final study cohort included 94,610 individuals who initiated GLP-1 RA or SGLT2i therapy during the study period, including 43,384 (45.9%) women with an overall mean age of 61.8 years. A total of 39,149 individuals submitted a claim for GLP-1 RA, of which 25,557 individuals (65.3%) achieved a PDC of 80% at 12 months.

Within the fully multivariable adjusted model, participants with an adjusted mean (adjusted odds ratio [aOR], 0.62; 95% CI, 0.58 – 0.67) or high (aOR, 0.47; 95% CI, 0.44 – 0.51) payment participation were significantly less likely to have a 12-month membership to the GLP-1 RA therapies, compared with those with low pay.

Meanwhile, the final cohort included 51,072 individuals with a pharmacy claim for an SGLT2i drug, of whom 37,339 (73.1%) individuals achieved a 12-month adherence (PDC 80%) for SGLT2i use. In the adjusted multivariable model, those with medium (aOR, 0.67; 95% CI, 0.63 – 0.72) or high (aOR, 0.68; 95% CI, 0.63 – 0.72) compensation were significantly less likely to have 12-month adherence to SGLT2i therapies than those with low co-payment.

Essien and colleagues indicated that these findings in a commercially insured cohort could have important implications for ensuring equitable access to the medical management of chronic cardiometabolic diseases.

Lowering the high costs of direct prescribing may be the key to improving adherence to guideline-recommended therapies and improving the overall quality of care in the management of T2D and heart failure, the researchers wrote.


  1. Essien UR, Singh B, Swabe G, et al. Association of prescription co-payment with adherence to glucagon-like peptide-1 receptor agonist and sodium glucose cotransporter-2 inhibitor therapies in patients with heart failure and diabetes. JAMA network open. 2023;6(6):e2316290. doi:10.1001/jamannetworkopen.2023.16290
  2. EberlyLA, YangL, EssienUR, etal. Racial, ethnic, and socioeconomic inquiries into the use of glucagon-like peptide-1 receptor agonists among patients with diabetes in the United States. JAMA Health Forum. 2021;2(12):e214182-e214182. doi:10.1001/jamahealthforum.2021.4182

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