Summary: In a secondary analysis of 1045 participants from the COORDINATE-Diabetes randomized trial, adults with Type 2 diabetes and atherosclerotic cardiovascular disease frequently stopped guideline-recommended therapy. Among those prescribed an SGLT-2 inhibitor, 23.1% discontinued; among those prescribed a GLP-1 receptor agonist, 32.2% discontinued. Up to one-third stopped within 12 months of initiation, with cost, side effects, and patient choice the most common reasons.
PICO Summary
| Element | Detail |
|---|---|
| Population | 1045 adults with Type 2 diabetes and atherosclerotic cardiovascular disease enrolled in US cardiology clinics (COORDINATE-Diabetes cluster-randomized trial, enrolled July 2019 to May 2022); secondary descriptive analysis. |
| Intervention | Prescription of an SGLT-2 inhibitor (n=290; 27.8% of cohort) and observed persistence versus discontinuation. |
| Comparison | Prescription of a GLP-1 receptor agonist (n=118; 11.3% of cohort); the analysis describes discontinuation within each class rather than comparing one drug against the other or against an untreated arm. |
| Outcome | SGLT-2i discontinuation: 67/290 (23.1%). GLP-1RA discontinuation: 38/118 (32.2%). Up to one-third stopped within 12 months. Medicare coverage was more common among those who discontinued: GLP-1RA 71.1% vs 49.4% (p=0.027); SGLT-2i 71.4% vs 58.1% (p=0.058). Race, age, and sex did not differ between discontinuers and persisters. Cost, side effects, and patient choice were the most cited reasons. No significance testing of cardiovascular or glycaemic endpoints was performed; no 95% CIs, ARR, or NNT are reported. |
Expert Commentary
This is an honest and useful descriptive snapshot, not a trial of efficacy. The authors took the COORDINATE-Diabetes database and asked a narrower question: once these cardioprotective agents are prescribed, how often are they stopped, and why? The headline that roughly a quarter to a third of patients discontinue within a year is sobering, and it is consistent with real-world pharmacy data showing that persistence on these drugs is fragile. The signal that Medicare coverage was associated with discontinuation, statistically significant for GLP-1 receptor agonists, points squarely at cost and access rather than tolerability alone, which fits the cited reasons of cost, side effects, and patient choice. The most important limitation is that this is an observational, secondary analysis of a modest sample, so the discontinuation percentages are associational and cannot be read as causal drivers; the GLP-1RA subgroup in particular is small at 118 patients, which widens uncertainty around its 32.2% figure. Readers should also note that two authors are employed by the drug manufacturers, so independent replication is reassuring to seek. Can I use this with my patients? Yes, as a prompt to actively check adherence and pre-empt cost barriers in anyone you start on an SGLT-2i or GLP-1RA, not as evidence about which drug to pick. Clinicians should build discontinuation conversations into routine follow-up rather than assuming a prescription equals sustained use.
References
Nelson AJ, Kaltenbach LA, McGuire DK, et al. Discontinuation of SGLT-2i and GLP-1RA among persons with Type 2 diabetes and atherosclerotic cardiovascular disease treated in US cardiology clinics. Am Heart J. 2024;282:51-57. doi:10.1016/j.ahj.2024.12.006