The number of Australian patients receiving incident SGLT2i monotherapy increased by 82% per year from 2020, while monotherapy with GLP-1RAs jumped by 73% a year from 2014, according to analysis of PBS data.

The review of 49,129 individuals by Melbourne researchers lays out the changing face of glucose-lowering drug initiation in Australia, with the data showing:

• Incident glucose-lowering drugs as monotherapy decreased from 90.4% in 2014 to 77.2% in 2024,
• Meanwhile, dual therapy rose from 9.3% to 21.8%, and triple therapy from 0.2% to 1.0%,
• Metformin as monotherapy fell from 82.7% to 29.1% between 2014 and 2024,
• GLP-1RA use shot up by 73% per year since 2014, and
• Incident SGLT2i monotherapy increased by 82.0% per year from 2020.

Writing in Diabetes, Obesity and Metabolism, University of Melbourne Associate Professor Peter Hamblin and colleagues said the data showed a marked change in medication patterns which were consistent with cardiorenal-oriented prescribing [link here].

A/Prof Peter Hamblin.

“The increase in initial dual and triple therapy may reflect earlier intensification, but may also reflect the availability of [fixed dose combinations], reimbursement changes, non-diabetes use or growing treatment of older, comorbid patients,” they said.

The shift towards treatments with confirmed cardiorenal benefits and away from metformin and DPP4i options had occurred despite no Australian guidelines recommending either GLP-1 medications or SGLT2is as first-line therapy, they said.

There was a marked drop in GLP-1RA initiation between 2023 and 2024, which the investigators said was likely due to a government campaign reminding prescribers that PBS rules dictate metformin and SGLT2is should be prescribed before a GLP-1.

Priorities beyond glycaemic control 

The move from metformin to the new generation of glucose-lowering drugs suggested clinicians were looking beyond purely glycaemic control when prescribing, the authors argued.

“This pattern may suggest that prescribers are incorporating cardiometabolic risk into initial treatment decisions, rather than relying on glucocentric or historically entrenched prescribing paradigms,” they said.

Meanwhile, one quarter of patients with T2D appear to be starting with dual therapy.

“While earlier use of combination therapy may offer potential clinical benefits, it also raises important questions regarding treatment complexity, adherence, equity of access and long-term real-world effectiveness,” the authors noted.

Because the data was drawn from a PBS dataset, some of the SGLT2i and GLP-1RA use may have been for patients without type 2 diabetes, which was a limitation of the study.