# Fill Patterns of Glucose-Lowering Drugs with Cardiovascular and Kidney Benefits in the Rural and Urban United States, 2012–2021

## TL;DR

This study examines how often diabetes drugs with heart and kidney benefits are prescribed in rural versus urban US areas from 2012 to 2021.

## Contribution

It identifies trends in drug access and shows that fills increased over time but remained low, with variations by age, sex, and comorbidities.

## Key findings

- Fills of GLP1RA/SGLT2i increased over time but remained low overall.
- Younger people, women, and those with ASCVD or CKD were more likely to fill these drugs.
- Small towns had slightly higher odds of fills compared to cities.

## Abstract

Glucagon-like peptide-1 receptor agonists (GLP1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) improve cardiovascular and kidney outcomes, but accessibility concerns persist. Whether access is worse in rural communities is unknown.

To examine fills of GLP1RA/SGLT2i by adults with type 2 diabetes in rural and urban US counties.

Cross-sectional use claims from OptumLabs® Data Warehouse, 2012–2021.

Adults with type 2 diabetes.

We examined rates and odds of fills of GLP1RA or SGLT2i, adjusting for time period, age, sex, presence of cardiorenal comorbidities (heart failure [HF], atherosclerotic cardiovascular disease [ASCVD], chronic kidney disease stages 3–4 [CKD]), and rurality.

The study included 2,579,577 adults with type 2 diabetes (mean age 63.9; 49.6% female). Compared to 2012–2015, fills of GLP1RA/SGLT2i increased in 2016–2018 (OR 2.49; 95% CI 2.47–2.52) and 2019–2021 (OR 4.35; 95% CI 4.30–4.39). By 2019–2021, the percentages of patients filling GLP1RA/SGLT2i in cities, small towns, and remote areas were 18.8%, 18.8%, and 17.4%, respectively. Small town residents had higher odds of fills than those in cities (OR 1.05; 95% CI 1.04–1.06). Older age was associated with lower fill rates; compared to 18–44 year olds, odds for those 45–64 years were OR 0.88 (95% CI 0.87–0.89), 65–74 years: OR 0.48 (95% CI 0.47–0.48), and ≥ 75 years: OR 0.17 (95% CI 0.17–0.18). Men were less likely to fill GLP1RA/SGLT2i than women (OR 0.91; 95% CI 0.90–0.92). Presence of ASCVD and CKD were associated with greater odds of filling GLP1RA/SGLT2i (OR 1.03 [95% CI 1.01–1.05] and OR 1.12 [95% CI 1.10–1.14], respectively), while HF was associated with lower odds (OR 0.86 [95% CI 0.85–0.88]).

GLP1RA and SGLT2i fills increased over time but remained low overall. They were filled more often by younger people, women, those with ASCVD or CKD (but not with HF), and in small towns.

The online version contains supplementary material available at 10.1007/s11606-025-09784-0.