Children and teens with type 2 diabetes are more likely to receive insulin than newer GLP-1 receptor agonists, according to a new study published in Pediatrics.

Current guidelines from the American Diabetes Association include recommendations for care of children and teens with type 2 diabetes, favoring non-insulin therapy when possible.

Short-acting insulin must be administered multiple times a day, can cause weight gain, and carries risks such as hypoglycemia. By contrast, newer GLP-1s such as dulaglutide and semaglutide are given once a week.

“GLP-1RAs are still used less than insulin; this is somewhat surprising given the updated guidelines, in addition to known weight and cardiometabolic benefits,” said Lina Alkhaled, MD, pediatric endocrinologist at the Cleveland Clinic in Cleveland, who was not associated with the new study.

GLP-1 RAs were first approved for youth with type 2 diabetes with liraglutide (Victoza) in 2019, followed by semaglutide (Wegovy) and dulaglutide (Trulicity) in 2022. Prior to these approvals, insulin and metformin were the only available options for treatment.

To assess trends in dispensing of GLP-1s to youth aged between 10 and 17 years with type 2 diabetes, researchers analyzed data from 2020 to 2023, comparing trends between those with Medicaid and commercial insurance.

Nearly 9000 youth were included who had pharmacy claims data and continuous insurance enrollment during the study period. Of these, 75% were Medicaid-insured.

The annual prevalence of GLP-1s dispensed to youth overall increased from 10.9% to 35.6% (P ≤ .001). However, the medications were less frequently dispensed in 2023 than either short-acting or long-acting insulin (43.4% and 49.5%, respectively).

Although the overall dispensing prevalence of GLP-1s was similar for Medicaid and commercially insured youth, types of GLP-1 RA dispensed differed by insurance, as shown in a regression analysis.

Those with commercial insurance showed the greatest increase in semaglutide dispensing, with a significant increase from 0.3% in 2020 to 15.2% in 2023 (P for trend < .001). The greatest increase in dulaglutide occurred in Medicaid-insured youth, from 1.2% in 2020 to 19.3% in 2023 (P for trend < .001).

The researchers also conducted another analysis of types of drugs dispensed during 2023, including 2400 of the youth. Of 187 youth who received semaglutide, more than 85% received the brand name Ozempic, which is not currently FDA-approved for patients younger than 18 years.

In this analysis, commercially insured youth were more likely to be dispensed off-label semaglutide (Ozempic), while Medicaid-insured youth were more likely to be dispensed formulations requiring daily injections, such as liraglutide. Medicaid-insured youth were also more likely to receive exenatide (adjusted prevalence ratio [aPR], 2.3; 95% CI, 1.2-4.2), liraglutide (aPR, 1.6; 95%, 1.2-2.1), or dulaglutide (aPR, 1.5; 95% CI, 1.2-2.0]) than commercially insured youth.

In a secondary analysis of race and ethnicity based on 1789 youth, the researchers found that in the Medicaid-insured group, Hispanic youth were less likely to be dispensed GLP-1s than White youth.

Patricia Y. Chu, MD, MHSc, MSCE, attending physician in the Division of Endocrinology and Diabetes at Children’s Hospital of Philadelphia, Philadelphia, said she was surprised Ozempic was commonly dispensed for teens with commercial insurance because the drug is not labeled or approved for use in youth.

“We would have expected GLP-1s with an FDA label for pediatric use, such as dulaglutide (Trulicity) or semaglutide (Wegovy), to be dispensed more frequently,” said Chu, who led the study.

Chu said additional research needs to be conducted to find out if clinicians are not prescribing GLP-1s or if prescriptions are being denied by insurers.

Clinicians should work to increase access to GLP-1 RAs for patients by advocating for appropriate therapy and appealing insurer denials when justified, Alkhaled said.

The study received no outside funding. Chu disclosed receiving support from the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute of General Medical Sciences. Alkhaled disclosed having no financial conflicts of interest.