Abstract
AIMS: To investigate glucose-lowering treatment trajectories preceding glucagon-like peptide-1 receptor agonist (GLP-1RA) initiation in UK primary care, while assessing alignment with contemporary UK clinical guidelines, considering calendar time, cardiovascular disease (CVD) history, and obesity status. MATERIALS AND METHODS: Using the IQVIA Medical Research Data (IMRD) incorporating data from THIN, a Cegedim Database, we included adults with type 2 diabetes initiating GLP-1RAs in UK primary care between 01 January 2007 and 30 June 2023. We described treatment trajectories from the first glucose-lowering therapy to GLP-1RA initiation, stratified by calendar time (GLP-1RA initiation pre- or post-01 January 2018, when guidelines started recommending sodium-glucose co-transporter-2 inhibitors [SGLT-2is] for those at high risk or established CVD), CVD history, and body mass index (BMI) ≥35 kg/m(2). RESULTS: We included 29 780 GLP-1RA initiators, with 62.2% (n = 18 517) initiating pre-2018 and 37.8% (n = 11 263) post-2018. Consistent over calendar time, most GLP-1RA initiators (63.5%) received their first GLP-1RA as fourth-line (35.4%) or later-line therapy (28.1%), with fewer initiating GLP-1RAs as first- (0.8%), second- (10.5%), or third-line (25.2%) treatments. After 2018, 50.8% of individuals initiating GLP-1RA therapy used SGLT-2is concomitantly, regardless of CVD status (47.8% with established CVD vs. 51.5% without). Individuals with BMI ≥35 kg/m(2) initiated GLP-1RA therapy earlier compared to those with BMI <35 kg/m(2) (46.3% vs. 29.1% as first-, second-, or third-line treatment). CONCLUSIONS: GLP-1RAs were predominantly initiated following ≥3 glucose-lowering agents, consistent with contemporary UK guidance (NG28). Post-2018, most GLP-1RA initiators received SGLT-2is concomitantly. However, CVD history did not influence prescribing patterns, underscoring missed opportunities to optimise the prevention of cardiovascular events and slow the progression of CVD.