https://bmjopen.bmj.com/content/16/2/e110395

Use of SGLT2 inhibitors and GLP-1 receptor agonists in patients with ischaemic heart disease and type 2 diabetes in Swedish primary care: a cross-sectional analysis of regional primary care registry data (QregPV)
Tobias Andersson1,2,
Johan-Emil Bager3,4,
Margareta Hellgren1,
Maria Åberg1,5,
Georgios Mourtzinis3,6

Abstract

Objectives

To assess the use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) among patients with coexisting ischaemic heart disease (IHD) and type 2 diabetes (T2D) in primary care, in relation to European guidelines.

Design

Cross-sectional observational study.
Setting 209 primary healthcare centres in Region Västra Götaland, Sweden (population 1.8 million in 2023).
Participants 14 414 patients with registered prevalent diagnoses of coexisting IHD and T2D, September 2023, in QregPV, the regional primary care quality of care register in Region Västra Götaland. Data on dispensed drugs were retrieved from the regional prescribed drug register, Digitalis.

Primary and secondary outcome measures

The primary outcome was the proportion of patients with dispensed SGLT2i or GLP-1 RA in relation to sex, age and primary healthcare centres (including private vs public ownership). The secondary outcome was estimated additional prescription costs.

Results

SGLT2i was dispensed to 37.2%, less often to women (adjusted OR (aOR) 0.64 (95% CI 0.59 to 0.70)). GLP-1 RA was dispensed to 10.0%, with no sex difference (aOR 1.04 (95% CI 0.92 to 1.18)). Use of SGLT2i and GLP-1 RA declined with age (p<0.001). Use across primary healthcare centres (95% central range) varied from 17.1% to 56.4% for SGLT2i and 0.0% to 23.4% for GLP-1 RA, without differences between private versus public primary healthcare centres (SGLT2i: aOR 0.95 (95% CI 0.85 to 1.06); GLP-1 RA: aOR 1.06 (95% CI 0.89 to 1.26)). Variation across primary healthcare centres was substantial (SGLT2i: adjusted median OR (aMOR) 1.29 (95% CI 1.23 to 1.36); GLP-1 RA: aMOR 1.48 (95% CI 1.37 to 1.62)). Treating all patients would increase the annual prescription costs, €3.9 million for SGLT2i and €10.4 million for GLP-1 RA.

Conclusion

SGLT2i and GLP-1 RA were underutilised in patients with coexisting IHD and T2D.

The sex disparity in SGLT2i use warrants attention, as does the substantial variation between primary healthcare centres and the challenges of implementing costly cardioprotective therapies.

Data availability statement
Data are available upon reasonable request. The data underlying this article cannot be shared publicly due to ethical and legal restrictions from Swedish authorities. Data can, however, upon reasonable request to the authors and with permission from Region Västra Götaland, be made available to researchers who meet the criteria for access to confidential data.
https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
https://doi.org/10.1136/bmjopen-2025-110395

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STRENGTHS AND LIMITATIONS OF THIS STUDY
• The study included 99.5% of all primary healthcare centres in the region, ensuring high internal validity.
• Variation in use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) was assessed across primary healthcare centres.
• Individual-level data on dispensed SGLT2i and GLP-1 RA, more accurately reflecting patients’ actual use than prescribed medication data.
• Limited data were available on comorbidities and individual socioeconomic factors.
• Variability in drug pricing and reimbursement policies may affect the generalisability of the findings to other healthcare settings.

From the article

Introduction
In type 2 diabetes (T2D) with or without concomitant ischaemic heart disease (IHD), the first-line choice for blood glucose-lowering medication has long been treatment with metformin. Since newer but also more expensive drugs, sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) have been shown to not only decrease blood glucose but also reduce the risk of cardiovascular (CV) morbidity and mortality, they are recommended in European Society of Cardiology (ESC) guidelines as first-line drugs for T2D in combination with IHD, before metformin and independent of blood glucose levels.1 2

In Sweden, the downgrading of metformin has not yet been fully reflected in clinical guidelines, where SGLT2i and/or GLP-1 RA are recommended in addition to metformin. However, increased use of SGLT2i and GLP-1 RA has been seen in patients under 80 years of age with T2D who have recently experienced a myocardial infarction.3

Low utilisation of SGLT2i and GLP-1 RA has been reported among patients in primary care with IHD and newly diagnosed T2D.4 However, less is known about patients with a heterogeneous duration of disease. Moreover, little is known about the usage of SGLT2i and GLP-1 RA in primary care among patients with IHD and T2D, or how it varies between primary healthcare centres (PHCCs) and by public versus private ownership. Studies of veterans in the USA have shown underuse of SGLT2i and GLP-1 RA in patients with IHD and T2D, with and without chronic kidney disease, with significant variation in usage between different healthcare facilities.5–7

A high level of co-payment for patients has been associated with a lower degree of adherence to SGLT2i and GLP-1 RA in heart failure and T2D.8 In Sweden, the cost of healthcare visits and prescribed medications is universally subsidised by the government with low out-of-pocket costs for the individual patient, potentially affecting the usage of SGLT2i and GLP-1 RA. Given the CV risk reduction associated with SGLT2i and GLP-1 RA, insufficient implementation may represent a missed opportunity for secondary prevention in a large and high-risk patient population.

The aim of this study was to explore the usage of SGLT2i and GLP-1 RA in primary care among patients with IHD and T2D, and how it varies according to age, sex and PHCCs, including whether public versus private ownership. We also aimed to estimate the potential additional cost for prescribed SGLT2i and GLP-1 RA if used according to ESC guidelines.

Conclusions
This large real-world study of patients with IHD and concomitant T2D in Swedish primary care shows higher usage of SGLT2i and GLP-1 RA than most previous reports.

However, both medication classes remain underutilised relative to ESC guidelines, particularly among older patients and, in the case of SGLT2i, also among women.

The study further reveals substantial variation in use across PHCCs, but with no difference between public and private providers.

These findings highlight the need to reduce unwarranted variation in prescribing practices and to address the implementation challenges associated with costly secondary prevention cardioprotective therapies.

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