Background
Sodium–glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP1RA) have substantially improved cardiovascular and renal outcomes in people with type 2 diabetes mellitus (PwT2D), shifting treatment paradigms from a purely glucose-centric approach towards comprehensive organ protection. Despite strong evidence and updated international guidelines, real-world data on the implementation of these recommendations - particularly in Germany - remain limited.
Objective
To assess the use of SGLT2i and GLP1RA in high-risk PwT2D with either established atherosclerotic cardiovascular disease (ASCVD) or indicators of high cardiovascular disease (CVD) risk, and/or heart failure (HF), and/or chronic kidney disease (CKD) in a German university hospital setting, and to identify predictors of non-treatment according to current guideline recommendations.
Methods
Clinical data were accessed and retrieved from Germany’s largest FHIR (Fast Healthcare Interoperability Resources) database at the University Hospital Essen containing over two billion resources (2019–2024). Using an open-source, interoperable Python client, FHIRPACK and the FHAN analytics toolkit, PwT2D were identified via ICD-10 and ATC codes, stratified by ASCVD, indicators of high cardiovascular disease (CVD) risk, HF, and CKD. Prescription trends, comorbidities, and biochemical parameters were analyzed using descriptive statistics and multivariate logistic regression to determine independent predictors of non-guideline-adherent therapy.
Results
Between 2019 and 2024, 19,684 PwT2D (mean age: 70.3 ± 11.2 years; female sex: 36.8 %; HbA1c 7.2 ± 1.5% (54.6 ± 16.4 mmol/mol)) with ASCVD/indicators of high CVD risk, HF, and/or CKD were identified. During the observation period, prescription rates of SGLT2i and/or GLP1RA rose continuously with a maximum of 48.7% of PwT2D in 2024 treated in accordance to guideline recommendations. In multivariate logistic regression, female sex (OR 1.33, 95% CI 1.14-1.55, p < 0.001) and age (OR 1.02, 95% CI 1.01-1.03, p < 0.0001) were identified as a significant predictor of being undertreated. Decreased GFR (OR 0.98, 95% CI 0.98-0.99, p < 0.0001), comorbidity count (OR 0.87, 95% CI 0.83-0.91, p < 0.0001), and medication count (OR 0.51, 95% CI 0.53-0.48, p < 0.0001) significantly increased the odds of guideline-adherent treatment.
Conclusion
Organ-protective therapy for PwT2D with ASCVD/indicators of high CVD risk, and/or HF, and/or CKD has increased but remains insufficient, with substantial treatment gaps in specific subgroups requiring further analysis. Greater awareness and targeted interventions are needed to ensure equitable implementation of guideline-directed diabetes care.
