“Newer medications, especially GLP-1 receptor agonists and SGLT2 inhibitors, have been shown in clinical trials to reduce diabetes complications,” particularly lower risks of heart attack, stroke, and progression to kidney disease, says Scott Pilla, MD, an assistant professor of medicine at Johns Hopkins Medicine in Lutherville, Maryland. “Newer medications also have a much lower risk of hypoglycemia [low blood sugar episodes], which is a common and potentially severe side effect.” In addition to having a 60 percent higher risk of being affected by type 2 diabetes than their white peers, as the Centers for Disease Control and Prevention (CDC) notes, Black Americans are more likely to develop the aforementioned complications, reports the National Kidney Foundation. “Our concern is that minorities, who may benefit the most from these newer medications, may not have equal access to them,” notes Dr. Pilla. In a study presented at the American Diabetes Association’s 80th Scientific Sessions in June 2020, researchers, including coauthor Pilla, analyzed medication usage data in the Look AHEAD (Action for Health in Diabetes) randomized trial of adults with type 2 diabetes — the majority of diabetes cases — and obesity. Specifically, they studied the use of newer medications that help the body manage insulin better or get rid of excess blood glucose, including GLP-1 (glucagon-like peptide 1) receptor agonists like Trulicity (dulaglutide); DPP-4 (dipeptidyl peptidase-4) inhibitors , including Januvia (sitagliptin); and SGLT2 (sodium-glucose cotransporter-2) inhibitors, such as Jardiance (empagliflozin). They found that the likelihood of starting a newer drug was 19 percent lower among Black participants than it was for white ones. Furthermore, they reported that education status, employment status, and health insurance coverage were not significantly associated with the outcomes they saw. Yet people with lower incomes were less likely to start newer medication. According to GoodRx, maximum retail prices at the pharmacy for GLP-1 receptor agonists, SGLT2 inhibitors, and DPP-4 inhibitors range between $118 and $1,300 per monthly supply. By comparison, the average retail price for metformin is $16.60, and it is often discounted. People with type 2 diabetes and heart disease who take SGLT2 inhibitors are less likely to die of heart disease, have a lower risk of heart failure, see less progression of chronic kidney disease, and are more likely to lose weight, according to a scientific statement issued by the American Heart Association in April 2020. Those taking GLP-1 receptor agonists such as Victoza (liraglutide) and Ozempic (semaglutide), specifically, have seen a lowered risk of major cardiovascular events, such as strokes and heart attacks. Metformin, SGLT2 inhibitors, and GLP-1 receptor agonists have low risks of hypoglycemia, according to the statement. RELATED: How to Talk to Your Doctor About SGLT2 Inhibitors Pharmacist Rohit Moghe, PharmD, used to work at a federally qualified health center in Philadelphia, and he observed a lack of insurance coverage as a barrier for accessing newer diabetes medication. Many of his patient were Black and brown people who were on state Medicaid insurance. “I wanted my patients to get on these drugs because I knew what benefits there were,” says Moghe, who is a spokesperson for the Association of Diabetes Care & Education Specialists. Yet, he says, the Medicaid plans aren’t adding new drugs to the list swiftly enough. This problem is compounded by greater reliance by Black people on Medicaid plans. Nationwide, 34 percent of Black people were on Medicaid insurance as of 2018, compared with 15 percent of white people, according to U.S. Census Bureau data analyzed by Kaiser Family Foundation. (Furthermore, that year 10 percent of Black people in the United States had no insurance at all, compared with 6 percent of white people, according to the Census Bureau.) Until recently, Moghe says, the GLP-1 receptor agonists he wanted to provide were not on Pennsylvania’s preferred drug list for Medicaid beneficiaries. Diabetes drugs that are on the list can be covered. Those that are non-preferred go through a prior authorization process to be covered. Victoza and Bydureon have been on the preferred list since at least 2016. Yet Trulicity, which received FDA approval as a type 2 diabetes treatment in 2014, made the list only this year, and Ozempic is still not on it. “As soon as I got coverage for GLP-1s, I started to use them,” Moghe says. He adds that once his patients who fit the prescribing criteria are able to make the switch to once-weekly GLP-1 receptor agonists such as Trulicity and Ozempic, they become less reliant on insulin and some may enjoy being free of their former basal-bolus insulin therapies. Also, they are more likely to stick to their new regimen. As Johns Hopkins Medicine describes, basal-bolus therapy involves multiple injections per day to keep blood sugar stable after meals and through periods of fasting. Moghe says he has encountered similar challenges in prescribing SGLT2 inhibitors. Farxiga (dapagliflozin) and Invokana (canagliflozin) hadn’t joined Jardiance on the list of Pennsylvania’s Medicaid preferred drug list until just this year. He argues that the federal government could play a stronger role in how insurers and pharmaceutical companies negotiate pricing and availability to ensure that all Americans have access to the medication they need. RELATED: Why Is Insulin So Expensive? (And 4 Tips to Better Afford Yours)
Side Effect Fears and Mistrust of Doctors May Dissuade Black Patients From Trying New Diabetes Drugs
Another reason for the racial gap in starting newer drugs may originate with patients, says Kristen Gill Hairston, MD, an endocrinologist and associate professor at Wake Forest Baptist Health in Winston-Salem, North Carolina. Occasionally Dr. Hairston, who is Black, sees greater apprehension from Black and brown patients about trying new medication, particularly if a friend or relative suffered a negative side effect. Nausea and fatigue, as well as excessive thirst and urination, are common SGLT2 inhibitor side effects, according to a July 2018 article by physicians in Federal Practitioner. This class of drugs also comes with increased risk of developing the following: diabetic ketoacidosis, a potentially life-threatening condition; kidney damage; infections of the genitals or urinary tract, particularly in women; amputations; and bone fractures. GLP-1 receptor agonist side effects can include nausea, diarrhea, headache, vomiting, weakness, or dizziness, and an increased risk for pancreatitis, according to the Endocrine Society. Historic mistrust of healthcare systems and providers among Black Americans is also a barrier to trying new medication, Hairston says. Many are aware of the infamous Tuskegee experiment, during which the U.S. Public Health Service studied Black men with syphilis between 1932 and 1972 without telling them they had it or offering treatment. A number of participants died of syphilis-related causes while researchers studied the natural progression of the disease. The National Bureau of Economic Research published a paper estimating that national disclosure in 1972 of the Tuskegee study, which it denounced, led to such widespread mistrust of doctors within the Black community that physician interactions for older Black men measurably decreased. As a result, the life expectancy of a Black man at age 45 had dropped 1.5 years by 1980. Healthcare providers can overcome mistrust, says Hairston. “Having a good relationship with the patient really helps.” To start, providers must honor the fact that a patient has a right to be apprehensive. Then they must explain why they are recommending the new medication and what side effects can be expected. “I try to explain my thought process and pros and cons of the medication choice. I then remind the patient that it is up to them and to let me know what they decide. I think reminding the patient that they are part of the process helps a lot, too.” RELATED: The Pros and Cons of SGLT2 Inhibitors
What to Do if You’re Having Trouble Affording New Diabetes Drugs
If your barrier to trying newer diabetes medication isn’t mistrust or apprehension but simply price — an increasing problem for many during the COVID-19 pandemic as people lose their jobs and employer insurance coverage — Hairston suggests that you check with the pharmaceutical company who makes the drug in question to see if you qualify for a patient assistance program. The following drug manufacturers have programs for free or lower-cost diabetes medication for the following GLP-1 receptor agonists, SGLT2 inhibitors, and DPP-4 inhibitors:
Novo Nordisk’s NovoCare — Ozempic, VictozaEli Lilly’s Lilly Cares — Trulicity, Tradjenta, JardianceJanssen CarePath — InvokanaAstraZeneca’s AZ&Me — Farxiga, Bydureon, Byetta
Meanwhile, Pilla believes more needs to be done by the healthcare industry to close the racial gap. “It’s clear that there are issues accessing newer diabetes medications. My opinion is that pharmaceutical companies and insurers should work to make the costs lower for patients who may especially benefit, such as those with preexisting heart or kidney disease or at a higher risk for those conditions, so that patients and physicians aren’t struggling to balance choosing the most effective treatment with high medication costs.”
