Atherosclerotic cardiovascular disease and heart failure occur more frequently in patients with type 2 diabetes mellitus. Therefore, the major goal of care of patients with type 2 diabetes is to reduce the incidence of these events. Both glucagon-like peptide agonists (GLP-1RA’s) and sodium-glucose co-transporter 2 inhibitors (SGLT2i’s) can independently improve glucose control and decrease the incidence of major adverse cardiac events (MACE). Researchers at Brigham and Women’s hospital in Massachusetts wondered if further benefit could be derived by combining SGLT2i’s with baseline GLP-1RA treatment.
Using data from 3 US claims datasets, Dave et al. identified patients taking either a SGLT2i or a sulfonylurea in addition to a GLP-1RA. Researchers selected sulfonylureas as the comparator group because although they lower blood glucose, they are not associated with any cardiovascular benefit. Researchers next created 12,584 propensity-scored matched pairs of patients managed with one of these two combinations. They compared patients on GLP-1RA plus a SGLT2i to patients on GLP-1RA plus a sulfonylurea. The team used the primary outcome measures of composite cardiovascular endpoint (CCE, consisting of myocardial infarction, stroke, and all-cause mortality) and heart failure hospitalization. There were 107 CCE events in the SGLT2i group vs. 129 in the sulfonylurea group. The decrease in CCE seen in the SGLT2I group occurred to fewer myocardial infarctions and all-cause mortality events. The number of strokes was not substantially lower. There were 141 heart failure hospitalizations in the SGLT2i group vs. 206 in the sulfonylurea group.
Researchers suggest that the additional cardiovascular protective effect conferred by the combination of SGLT2i’s and GLP-1RA’s justify its use in routine clinical care. They acknowledge that the cost of implications of this combination may be inhibitory. Furthermore, some patients who experience adverse events associated with these medications will deem them intolerable.
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Author: Kelly Schoonderwoerd
Original article: Dave et al. Circulation 11 December 2020.