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SGLT2i and GLP-1RA in Older Adults With T2D
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This study evaluated the comparative effectiveness and safety of sodium–glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide 1 receptor agonists (GLP-1RA) among older adults using Medicare data.
- Compared with those taking GLP-1RA, individuals on SGLT2is had similar risk of major adverse cardiovascular events, decreased hospitalization for heart failure, but had increased risk of diabetic ketoacidosis, lower limb amputations, and urinary tract infections.
abstract
This abstract is available on the publisher's site.
Access this abstract nowOBJECTIVE
Both sodium–glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RA) demonstrated cardiovascular benefits in randomized controlled trials of patients with type 2 diabetes (T2D) generally <65 years old and mostly with cardiovascular disease. We aimed to evaluate the comparative effectiveness and safety of SGLT2i and GLP-1RA among real-world older adults.
RESEARCH DESIGN AND METHODS
Using Medicare data (April 2013–December 2016), we identified 90,094 propensity score-matched (1:1) T2D patients ≥66 years old initiating SGLT2i or GLP-1RA. Primary outcomes were major adverse cardiovascular events (MACE) (i.e., myocardial infarction, stroke, or cardiovascular death) and hospitalization for heart failure (HHF). Other outcomes included diabetic ketoacidosis (DKA), genital infections, fractures, lower-limb amputations (LLA), acute kidney injury (AKI), severe urinary tract infections, and overall mortality. We estimated hazard ratios (HRs) and rate differences (RDs) per 1,000 person-years, controlling for 140 baseline covariates.
RESULTS
Compared with GLP-1RA, SGLT2i initiators had similar MACE risk (HR 0.98 [95% CI 0.87, 1.10]; RD -0.38 [95% CI -2.48, 1.72]) and reduced HHF risk (HR 0.68 [95% CI 0.57, 0.80]; RD -3.23 [95% CI -4.68, -1.77]), over a median follow-up of ∼6 months. They also had 0.7 more DKA events (RD 0.72 [95% CI 0.02, 1.41]), 0.9 more LLA (RD 0.90 [95% CI 0.10, 1.70]), 57.1 more genital infections (RD 57.08 [95% CI 53.45, 60.70]), and 7.1 fewer AKI events (RD -7.05 [95% CI -10.27, -3.83]) per 1,000 person-years.
CONCLUSIONS
Among older adults, those taking SGLT2i had similar MACE risk, decreased HHF risk, and increased risk of DKA, LLA, and genital infections versus those taking GLP-1RA.
Additional Info
Disclosure statements are available on the authors' profiles:
Comparative Effectiveness and Safety of Sodium–Glucose Cotransporter 2 Inhibitors Versus Glucagon-Like Peptide 1 Receptor Agonists in Older Adults
Diabetes Care 2021 Jan 25;[EPub Ahead of Print], E Patorno, A Pawar, LG Bessette, DH Kim, C Dave, RJ Glynn, MN Munshi, S Schneeweiss, DJ Wexler, SC KimFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Diabetes
Diabetes is associated with an increased risk of cardiovascular disease (CVD)1 and renal impairment.2 These complications are more prevalent and often accelerated in older adults, in part due to the presence of risk factors and comorbidities that make treatment of type 2 diabetes (T2DM) particularly challenging in elderly patients. Newer clinical guidelines recommending initiation of glucagon-like peptide 1 receptor agonists (GLP1-RAs) and sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with T2DM and the aforementioned comorbidities3 are based on landmark randomized control trials (RCTs) that showed reductions in composite major adverse cardiovascular events, hospitalizations for heart failure, and progression of chronic kidney disease with these medications.4 Unfortunately, there are limited head-to-head data regarding the use of these agents in older adults.
The authors reviewed Medicare data in over 90,000 patients ≥66 years of age and with T2DM who were started on an SGLT2 inhibitor or a GLP-1RA. The primary objective of this population-based cohort study was to review the cardiovascular effectiveness of these medications in older adults. One of the most important conclusions of this study was that, in older adults with established CVD, the use of an SGLT2 inhibitor was associated with fewer hospitalizations for heart failure, cardiovascular deaths, and all-cause mortality compared with a GLP-1RA. Adverse events that are commonly associated with the two classes of medications were consistent with findings in the RCTs. Although this review was not an RCT, these results provide important data to providers for clinical decision–making on the optimal management of T2DM in elderly patients, a vulnerable population for whom treatment options with evident benefits regarding important clinical endpoints are limited.
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