*Purpose: The purpose of this study was to evaluate the utilization of and identify opportunities to optimize the use of glucagon-like peptide-1 receptor agonist (GLP-1 RA) use in the solid organ transplant population.

*Methods: This retrospective cohort study included solid organ transplant recipients with a history of either type 2 diabetes mellitus (T2DM) or post-transplant diabetes mellitus (PTDM) who were prescribed a GLP-1 RA after transplant between August 31, 2015 and August 31, 2020. Subjects less than 18 years old or with a history of type 1 diabetes were excluded. The primary outcome was the frequency of GLP-1 RA prescribing in solid organ transplant patients. Secondary outcomes included adverse effects, optimization of dosing based on package insert recommendations, persistency of use at 3, 6, and 12 months from initiation, cost, annual incidence of GLP-1 RA use, and prescriber specialty.

*Results: There was a total of 193 patients included in the analysis. The average patient was a 58-year-old white male with an A1c of 8.2%. The most frequently transplanted organs were kidney (n=124) and liver (n=41). The average estimated GFR was >30 mL/min/m² in 91.2% of patients. The primary endpoint showed that 5.2% of solid organ transplant patients with T2DM or PTDM were prescribed a GLP-1 RA. The endocrinology team was responsible for 69.4% of prescribing. Concomitant antidiabetic medications at the time of GLP-1 RA start included: long-acting insulin (59%), rapid-acting insulin (38%), sulfonylureas (26%), metformin (22%), insulin NPH (10%), and none (5%). Therapy with GLP-1 RA was initiated over 1 year after transplant in 70.4% of individuals. Medication persistence at 1 year was observed in 75% of patients with dosing titration occurring in 68.4% of these patients. Of patients who discontinued within the first year of use, 2.1% discontinued due to medication access issues and 5% of patients never picked up from the pharmacy mostly due to cost. Medication intolerance leading to discontinuation prior to 1 year was observed in 9.3% of patients with gastrointestinal intolerance being the most common reason.

*Conclusions: GLP-1 RAs are widely underutilized in the transplant population though they pose positive effects related to glycemic control, weight loss, and cardiovascular benefit. Despite the mean A1c only being 8.2% at the start of therapy, GLP-1 RAs were primarily used as adjunct therapy to insulin and started over a year after transplant. A pathway for the management of DM post-transplant can be developed to improve patient care and encourage appropriate utilization of metformin and GLP-1 RAs post-transplant, develop guidance for transitioning from insulin early post-transplant, and assist in patient follow-up. Though these agents are often not used due to concerns related to cost, this study shows that cost was not the primary reason for agent discontinuation prior to 1 year.

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