Characteristics of Glucagon-like peptide-1 (GLP-1) receptor agonists users without a diabetes diagnosis recorded in the Swedish National Diabetes Register

Background: In Sweden, where diabetes medications are subsidized, but obesity treatment is self-funded, shortage of Glucagon-like peptide-1 receptor agonists (GLP-1) has led to unregulated off-label prescription of GLP-1 for obesity treatment. This shift raises concerns about potential inequalities in care.

Objectives: This study aims to identify socioeconomic and demographic characteristics of GLP-1 users without a diabetes diagnosis recorded in the Swedish National Diabetes Register (NDR).

Methods: This is a register-based cohort study of individuals who filled at least one prescription of GLP-1 (ATC code A10BJ) identified in the Prescribed Drug Register (PDR) from January 1, 2018, the year when semaglutide was introduced in the European Union and in the Swedish market, to September 30, 2022. The source population was then linked to the NDR to exclude individuals with a diagnosis of diabetes. In addition, individuals with filled prescriptions of insulins and analogues (ATC code A10A) at any time prior to index GLP-1 analogue prescription were also excluded. Finally, the Total Population Register, the Longitudinal Integrated Database for Health Insurance and Labour Market Studies, and the PDR were used to describe individuals’ socioeconomic and demographic characteristics, and regional prescription trends.

Results: The final study population included 16,436 individuals with at least one GLP-1 prescription, without a recorded diagnosis of diabetes in the NDR, of which 70.1% were women, 30.7% had used anti-obesity medications, 14.1% mirtazapine, and 9.8% any antipsychotics prior to index GLP-1 analogue prescription. The proportion of users increased from 10.4% in 2018 to 38.4% in 2022. Overall 82.8% of users had an education longer than 9 years and higher family disposable income when compared to the average family disposable income over the study period in Sweden. Compared to men, women were more likely to have an education longer than 9 years (84.8% versus 78.3%), lower individual and family disposable income, and to be divorced (20,1% versus 15.6%). Among GLP-1 users who had prescriptions of anti-obesity medications prior to index GLP-1, 78.8% were women. Overall among GLP-1 users without a diagnosis of diabetes in NDR, 65.3% had Sweden as country of origin and 17.2% an Asian country. The regional variation in prescriptions varied four-fold.

Conclusions: Socioeconomic factors including income and education, sex, region and use of prior anti-obesity medications affect the likelihood of being prescribed GLP-1 analogues without having a diabetes diagnosis recorded in NDR. The findings underscore challenges related to the global shortage of GLP-1 analogues and emphasize the need for a more equitable approach to diabetes and obesity treatment.