Recommendations in NICE’s type 2 diabetes guideline update published today will enhance the use of SGLT-2 inhibitors in primary care and address these health inequalities.
NICE analysis conducted in 2024 revealed significant disparities in SGLT-2 inhibitor prescriptions for type 2 diabetes patients in England. The study, examining records of almost 590,000 people, found these medications, which protect the heart and kidneys whilst lowering blood sugar levels, are particularly under-prescribed to women, older people and Black or Black British individuals.
Key findings show only one in five people with atherosclerotic cardiovascular disease (ASCVD) received SGLT-2 prescriptions. Age-related disparities were stark – 32% of people aged 50 to 59 with ASCVD received prescriptions compared to just 13% of those aged 80-89. Gender differences were also notable, with men (35%) more likely to receive prescriptions than women (23%) among people with heart failure.
Several factors contribute to these inequalities. For older people, concerns about medication interactions may limit prescriptions. Women’s lower prescription rates might relate to urinary tract infection (UTI) risks and pregnancy considerations, though given the age distribution of the eligible population the former factor is likely to be much more relevant. Black or Black British people with ASCVD and those in deprived areas with ASCVD had 22% and 15% lower odds of receiving prescriptions respectively.
We have updated our guidelines to recommend SGLT-2 inhibitors as first-line treatment for all diabetes patients, not just those with heart disease. The updated guidance also calls for research to better understand and address these prescribing disparities.
Benefit of increased use
NICE findings from the research (detailed below) suggest that a uniform and safe increase in SGLT-2 inhibitors’ uptake would bring the greatest benefits for people in deprived areas and ethnic minorities, where type 2 diabetes is more prevalent.
“There is some urgency to find ways to increase the uptake of SGLT-2 inhibitors because if we were to achieve perfect uptake the nation would be significantly healthier,” said Dr Waqaar Shah, a GP partner at Chatfield Health Care in London and committee chair for the newly published type 2 diabetes guideline update. “That has benefits primarily for the patient but also for the healthcare system, potentially reducing the use of resources associated with health complications.”
Diabetes – a condition where someone has too much glucose (sugar) in their blood – costs the NHS £1 million per hour, about 10% of its entire budget. According to Diabetes UK, every week diabetes leads to more than 930 strokes, 660 heart attacks, and almost 2,990 cases of heart failure in the UK. It is estimated that 60% of NHS spending on diabetes goes towards treating complications.
What are SGLT-2 inhibitors?
Sodium-glucose co-transporter-2 (SGLT-2) inhibitors are once-a-day tablets to treat type 2 diabetes. They reduce blood sugar levels by helping the kidneys remove excess sugar from the body. They can also protect against heart failure and heart attacks.
The 2022 type 2 diabetes NICE guideline recommended SGLT-2 inhibitors for adults with type 2 diabetes and co-existing chronic heart failure (CHF) or ASCVD. It advised doctors consider the medicine for people at high risk of developing cardiovascular disease (CVD).
Low uptake
The analysis of primary care data found that the proportion of people prescribed SGLT-2 inhibitors was low: Only one in five people with comorbid ASCVD or at high risk of CVD had a current prescription for one of these medicines, compared to about one in three patients with CHF.
The updated guidance recommending SGLT-2 inhibitors as a first-line treatment for everyone with diabetes will raise awareness of the treatment among healthcare professionals and increase uptake for all patient groups.
Inequality of access
Older age groups were less likely to have a current SGLT-2 inhibitor prescription.
Figure 1: Proportion of type 2 diabetes patients with an SGLT-2 inhibitor prescription in England, by age group and comorbidity
Note: Data as of 1 September 2023, 18 months after the recommendations were published. Includes people aged 18 or over. Source: NICE analysis of Clinical Practice Research Datalink (CPRD) data.
For people with ASCVD, 32% of patients aged 50-59 had a current prescription, while only 13% of those aged 80-89 had one. Similar age-related trends were seen in people with heart failure or high CVD risk.
“As people age, they are more likely to be on a larger number of medications than before. There may be a concern of side effects or interactions of the new drug with their stable portfolio of medicines. Patients may also resist switching to a new medication if the current diabetic treatment is working,” said Dr Shah.
Health inequalities were also observed by gender: About one in four women (23%) with comorbid heart failure had a prescription, compared to approximately one in three men (35%). A similar pattern was seen in women with ASCVD or high CVD risk.
Figure 2: Proportion of type 2 diabetes patients with an SGLT-2 inhibitor prescription in England, by gender and comorbidity
Note: Data as of 1 September 2023, 18 months after the recommendations were published. Includes people aged 18 or over. Source: NICE analysis of Clinical Practice Research Datalink (CPRD) data.
UTIs and thrush are common side effects of this medication, which may contribute to the lower use in women.
“SGLT-2 inhibitors are not approved for use in pregnant or breastfeeding patients, which can hinder prescribing for women,” said Dr Rahul Mohan, a GP at West Bridgford Medical Centre in Nottingham and Secretary of the Primary Care Diabetes Society.
A lower percentage of Black or Black British people than White people had a prescription. This was the case across all groups (ASCVD, CHF or high CVD risk) but the differences were smaller than by age or gender.
Among patients with high CVD risk, 16% of Black or Black British people were prescribed the medicines, compared with 21% of White people.
Figure 3: Proportion of type 2 diabetes patients with an SGLT-2 inhibitor prescription in England, by ethnicity and comorbidity
Note: Data as of 1 September 2023, 18 months after the recommendations were published. Includes people aged 18 or over. Source: NICE analysis of Clinical Practice Research Datalink (CPRD) data.
Additional modelling found that people aged 70-79 with type 2 diabetes and ASCVD had less than half the odds of a current prescription compared to those aged 18-39, and women had 2/3rds the odds of men. Black and Black British people had 22% lower odds of having a current prescription than White people. In addition, this analysis found that patients living in the most deprived areas had about 15% lower odds of a prescription than those from the least deprived areas. Similar results were observed in the model for patients with type 2 diabetes and CHF.
“People living in areas of higher deprivation and certain ethnic minority groups are what we call ‘seldom heard’ groups. They tend to visit their doctor or attend their appointments less often, which could explain the disparities,” said Dr Soon Song, Consultant Physician and Diabetologist at Sheffield Teaching Hospitals NHS Foundation Trust and committee member for the type 2 diabetes guideline update.
“We need to devise a more innovative way of providing services to reach these groups, educating and empowering patients to help them follow their treatment plan,” he added.
Encouraging appropriate prescribing
The findings informed the medicines update of the type 2 diabetes guideline, which was published today.
Dr Shah said: “We [NICE’s independent committee] have made a research recommendation because we want to understand with some level of granularity exactly the reasons for this inequality. I think that research will generate answers that we can then use to inform future recommendations.”
The evidence from our analysis is clear. There are prescribing gaps that need to be addressed. The guideline update published today will help to increase equitable uptake of SGLT-2 inhibitors, which we know can prevent serious health complications. NICE used this real-world evidence to inform these research recommendations, which will result in powerful data to help further reduce health inequalities.
Professor Jonathan Benger, chief medical officer at NICE
Several initiatives at a local level aim to encourage appropriate prescribing of SGLT-2 inhibitors.
Dr Mohan has led training sessions in different areas of his Integrated Care Board (ICB), across Nottingham and Nottinghamshire: “The audience is a mixture of GPs, practice nurses, healthcare assistants, and other primary care professionals. Some improvement in the SGLT-2 inhibitor prescribing has happened, but much more needs to be achieved.”
Primary care learning events on this topic have also taken place in other regions, including South Yorkshire and London.
Experts also highlighted the importance of using SGLT-2 inhibitors safely. They are associated with a risk of diabetic ketoacidosis (DKA), a condition that is preventable and can be fatal.
Dr Song said: “We need to use SGLT-2 inhibitors more, but we must do so safely to minimise the risk of diabetic ketoacidosis. People on a low-calorie diet or those going for surgery should avoid this medication. Patients with any acute illness should stop taking it until they are fully recovered.”