Clinical question: Determine the cardiovascular risk outcome in type II diabetic patients initiated on an sodium-glucose cotransporter-2 (SGLT2) inhibitor versus a glucagon-like peptide-1 (GLP-1) receptor agonist.
Background: Various studies have suggested that several SGLT2 inhibitors and GLP-1 receptor agonists may improve cardiac outcomes—myocardial infarction, stroke, hospitalization for heart failure, and cardiovascular death. Current guidelines recommend using either an SGLT2 inhibitor or GLP-1 receptor agonist for patients with type II diabetes and cardiovascular disease. However, there has been no study directly comparing SGLT2 inhibitors with GLP-1 receptor agonists in patients with type II diabetes.
Study design: 1:1 propensity matched, population-based, cohort study
Setting: The data was retrieved from two commercial U.S. health insurance data sets: #1 Optum’s deidentified Clinformatics Data Mart and IBM Market Scan Database; and #2 Medicare fee-for-service Parts A, B, and D from April 1, 2013, to December 31, 2017.
Synopsis: 186,040 propensity score-matched patients were stratified by cardiovascular disease status and analyzed to assess differences in cardiovascular risk in patients initiated on either an SGLT-2 inhibitor or GLP-1 receptor agonist. The primary outcome was a composite cardiovascular endpoint of hospitalization for acute myocardial infarction (MI), stroke, or heart failure. The median follow-up was approximately seven months. The initiation of SGLT-2 inhibitors versus GLP-1 receptor agonists demonstrated a lower risk of hospitalization for MI (HR, 0.83 [95% CI, 0.74 to 0.93]) and risk for a composite outcome of MI, stroke, or all-cause mortality (HR, 0.90 [95% CI, 0.82 to 0.98]). There was no difference in the risk for all-cause mortality in those who received SGLT-2 inhibitors versus GLP-1 receptor agonists. The initiation of SGLT-2 inhibitors was associated with an approximately 30% reduction in the risk for heart failure hospitalization in all patients—regardless of cardiovascular disease status—when compared to patients initiated on GLP-1 receptor agonists (HR, 0.70 [CI, 0.64 to 0.77]).
Bottom Line: Both SGLT-2 inhibitors and GLP-1 receptor agonists decrease cardiovascular risk in patients with type II diabetes and cardiovascular disease. However, SGLT-2 inhibitors may decrease the risk of hospitalizations from heart failure more than GLP-1 receptor agonists regardless of a patient’s cardiovascular disease history.
Citation: Patorno E, et al. Sodium-glucose cotransporter-2 inhibitors versus glucagon-like peptide-1 receptor agonists and the risk for cardiovascular outcomes in routine care patients with diabetes across categories of cardiovascular disease. Ann Intern Med. 2021;174(11):1528-1541. doi:10.7326/M21-0893.
Dr. Huang is the senior medical director of hospital medicine at Atrium Health Enterprise, the hospital medicine executive medical director at Atrium Wake Forest Baptist Health System, and an associate professor of internal medicine at Wake Forest School of Medicine, Winston-Salem, N.C. Disclosure: Dr. Huang is a scientific advisory board member for Medicus Tek and a hospital medicine editor and board member for Dynamed Plus.