Impact of Prior Authorization Removal on SGLT2 Inhibitor Utilization

A study presented at the 2024 ASHP Midyear Clinical Meeting and Exhibition investigated the impact of lifting prior authorization (PA) restrictions on the utilization of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in a large primary care safety net clinic. SGLT2i, known for their benefits in patients with type 2 diabetes and cardiovascular or renal diseases, have been underutilized despite strong evidence of their effectiveness. The PA restriction on SGLT2i was removed at the clinic on May 23, 2023, and this study aimed to observe changes in the initiation rate of SGLT2i before and after the PA removal. 

The study was conducted at a large clinic in Los Angeles County serving a diverse population, used a retrospective observational design. It included primary care visits from December 2022 to September 2023 for patients aged 18 or older who were diagnosed with type 2 diabetes, and who had not previously been prescribed SGLT2i. Exclusions were made for specialty clinic visits or conditions such as cancer treatments, hemodialysis, or pregnancy. Eligibility for SGLT2i was based on American Diabetes Association (ADA) guidelines, including a history of cardiovascular disease, heart failure, or chronic kidney disease. 

A total of 305 visits were randomly selected, representing 284 unique patients, predominantly Hispanic/Latino patients (88.4%) and those with Medicaid insurance (92.3%). The most common comorbidities were hypertension (89.8%), obesity (66.2%), and hyperlipidemia (62.7%). While SGLT2i initiation rates were low throughout the study period, there was a significant 79.9% increase in the likelihood of initiation following the PA removal, though statistical significance was not reached (P = .356). 

Reasons for not initiating SGLT2i included patient decline (8 visits), provider preference for lifestyle modifications first (37 visits), and patient nonadherence to medications (36 visits). Despite the increased likelihood of SGLT2i initiation after the PA removal, the overall utilization remained low. Although lifting the PA restriction led to a trend of increased SGLT2i initiation, the overall rate remained limited.  

Reference 

Phan D, Bae-Shaaw Y. Trend of SGLT2i prescription before and after prior authorization removal. Presented at: ASHP Midyear 2024 Clinical Meeting and Exhibition; December 9, 2024; New Orleans, Louisiana.