To examine whether glucagon-like peptide 1 receptor agonists (GLP-1RA) and sodium–glucose cotransporter 2 inhibitors (SGLT2i) are preferentially initiated among patients with cardiovascular disease, heart failure (HF), or nephropathy, where these drug classes have established benefit, compared with dipeptidyl peptidase 4 inhibitors (DPP-4i), for which corresponding benefits have not been demonstrated.

We retrospectively analyzed claims of adults with type 2 diabetes included in OptumLabs Data Warehouse, a deidentified database of commercially insured and Medicare Advantage beneficiaries, who first started GLP-1RA, SGLT2i, or DPP-4i therapy between 2016 and 2019. Using multinomial logistic regression, we examined the relative risk ratios (RRR) of starting GLP-1RA and SGLT2i compared with DPP-4i for those with a history of myocardial infarction (MI), cerebrovascular disease, HF, and nephropathy after adjusting for demographic and other clinical factors.

We identified 75,395 patients who started GLP-1RA, 58,234 who started SGLT2i, and 91,884 who started DPP-4i. Patients with prior MI, cerebrovascular disease, or nephropathy were less likely to start GLP-1RA rather than DPP-4i compared with patients without these conditions (RRR 0.83 [95% CI 0.78–0.88] for MI, RRR 0.77 [0.74–0.81] for cerebrovascular disease, and RRR 0.87 [0.84–0.91] for nephropathy). Patients with HF or nephropathy were less likely to start SGLT2i (RRR 0.83 [0.80–0.87] for HF and RRR 0.57 [0.55–0.60] for nephropathy). Both medication classes were less likely to be started by non-White and older patients.

Patients with cardiovascular disease, HF, and nephropathy, for whom evidence suggests a greater likelihood of benefiting from GLP-1RA and/or SGLT2i therapy, were less likely to start these drugs. Addressing this treatment/benefit paradox, which was most pronounced in non-White and older patients, may help reduce the morbidity associated with these conditions.

检查胰高血糖素样肽 1 受体激动剂 (GLP-1RA) 和钠 - 葡萄糖协同转运蛋白 2 抑制剂 (SGLT2i) 是否优先在心血管疾病、心力衰竭 (HF) 或肾病患者中使用，这些药物类别已确定获益，与二肽基肽酶 4 抑制剂 (DPP-4i) 相比，其相应的益处尚未得到证实。

我们回顾性分析了 OptumLabs 数据仓库中包含的 2 型糖尿病成年人的索赔，该数据仓库是一个商业保险和 Medicare Advantage 受益人的去识别数据库，他们在 2016 年至 2019 年期间首次开始 GLP-1RA、SGLT2i 或 DPP-4i 治疗。使用多项逻辑回归，我们在调整人口统计学和其他临床因素后，比较了有心肌梗塞 (MI)、脑血管疾病、HF 和肾病病史的患者开始 GLP-1RA 和 SGLT2i 与 DPP-4i 的相对风险比 (RRR)。

我们确定了启动 GLP-1RA 的 75,395 名患者、启动 SGLT2i 的 58,234 名患者和启动 DPP-4i 的 91,884 名患者。与没有这些疾病的患者相比，有既往 MI、脑血管疾病或肾病的患者开始 GLP-1RA 而不是 DPP-4i 的可能性较小（MI 的 RRR 0.83 [95% CI 0.78–0.88]，RRR 0.77 [0.74–0.81]脑血管疾病，肾病 RRR 0.87 [0.84–0.91]）。患有 HF 或肾病的患者不太可能开始 SGLT2i（HF 的 RRR 0.83 [0.80–0.87] 和肾病的 RRR 0.57 [0.55–0.60]）。非白人和老年患者不太可能开始这两种药物类别。

患有心血管疾病、心衰和肾病的患者（有证据表明更有可能从 GLP-1RA 和/或 SGLT2i 治疗中获益）不太可能开始使用这些药物。解决这种在非白人和老年患者中最为明显的治疗/益处悖论可能有助于降低与这些疾病相关的发病率。