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Comparative Study
. 2024 Aug 20;84(8):696-708.
doi: 10.1016/j.jacc.2024.06.016.

Kidney and Cardiovascular Effectiveness of SGLT2 Inhibitors vs GLP-1 Receptor Agonists in Type 2 Diabetes

Daniel Edmonston  1 , Hillary Mulder  2 , Elizabeth Lydon  2 , Karen Chiswell  2 , Zachary Lampron  2 , Christina Shay  3 , Keith Marsolo  4 , Raj C Shah  5 , W Schuyler Jones  6 , Howard Gordon  7 , Wenke Hwang  8 , Isabella Ayoub  9 , Daniel Ford  10 , Alanna Chamberlain  11 , Ajaykumar Rao  12 , Vivian Fonseca  13 , Alexander Chang  14 , Faraz Ahmad  15 , Adriana Hung  16 , Kelly Hunt  17 , Javed Butler  18 , Hayden B Bosworth  19 , Neha Pagidipati  20
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Free article
Comparative Study

Kidney and Cardiovascular Effectiveness of SGLT2 Inhibitors vs GLP-1 Receptor Agonists in Type 2 Diabetes

Daniel Edmonston et al. J Am Coll Cardiol. .
Free article

Abstract

Background: Emerging data suggest that glucagon-like peptide-1 receptor agonists (GLP-1 RAs) improve kidney outcomes for people with type 2 diabetes (T2D). Direct comparisons of the kidney and cardiovascular effectiveness of GLP-1 RA with sodium-glucose cotransporter 2 inhibitors (SGLT2i), a first-line therapy for this population, are needed.

Objectives: The authors compared kidney and cardiovascular outcomes for new users of SGLT2i and GLP-1 RAs with T2D.

Methods: Using propensity score overlap weighting, we analyzed electronic health record data from 20 U.S. health systems contributing to PCORnet between 2015 and 2020. The primary kidney outcome was a composite of sustained 40% estimated glomerular filtration rate (eGFR) decline, incident end-stage kidney disease, or all-cause mortality over 2 years or until censoring. In addition, we examined cardiovascular and safety outcomes.

Results: The weighted study cohort included 35,004 SGLT2i and 47,268 GLP-1 RA initiators. Over a median of 1.2 years, the primary outcome did not differ between treatments (HR: 0.91; 95% CI: 0.81-1.02), although SGLT2i were associated with a lower risk of 40% eGFR decline (HR: 0.77; 95% CI: 0.65-0.91). Risks of mortality (HR: 1.08; 95% CI: 0.92-1.27), a composite of stroke, myocardial infarction, or death (HR: 1.03; 95% CI: 0.93-1.14), and heart failure hospitalization (HR: 0.95; 95% CI: 0.80-1.13) did not differ. Genital mycotic infections were more common for SGLT2i initiators, but other safety outcomes did not differ. The results were similar regardless of chronic kidney disease status.

Conclusions: SGLT2i and GLP-1 RAs led to similar kidney and cardiovascular outcomes in people with T2D, though SGLT2i initiation was associated with a lower risk of 40% eGFR decline. (Evaluating Comparative Effectiveness of Empagliflozin in Type 2 Diabetes Population With and Without Chronic Kidney Disease; NCT05465317).

Keywords: cardiovascular disease; chronic kidney disease; diabetes mellitus; glucagon-like 1 receptor agonists; sodium-glucose cotransporter 2 inhibitors.

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Conflict of interest statement

Funding Support and Author Disclosures This study was funded by the Boehringer Ingelheim & Lilly Diabetes Alliance. The authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICMJE). Boehringer Ingelheim was given the opportunity to review the manuscript for medical and scientific accuracy as well as intellectual property considerations. Dr Butler has received consultant honoraria from Abbott, American Regent, Amgen, Applied Therapeutic, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Cardiac Dimension, Cardior, CVRx, Cytokinetics, Edwards, Element Science, Innolife, Impulse Dynamics, Imbria, Inventiva, Lexicon, Lilly, LivaNova, Janssen, Medtronics, Merck, Occlutech, Novartis, Novo Nordisk, Pfizer, Pharmacosmos, Pharmain, Roche, Sequana, SQ Innovation, and Vifor. Dr Pagidipati has received research support from Alnylam, Amgen, Boehringer Ingelheim, Eggland’s Best, Eli Lilly, Novartis, Novo Nordisk, and Verily Life Sciences; has served on consultation/advisory panels for Bayer, Boehringer Ingelheim, CRISPR Therapeutics, Eli Lilly, Esperion, AstraZeneca, Merck, Novartis, and Novo Nordisk; has served as an executive committee member for trials sponsored by Novo Nordisk and Amgen; has served on the Data Safety Monitoring Boards for trials sponsored by Johnson and Johnson and Novartis; and has served on the medical advisory board for Miga Health. Dr Fonseca has received research support (to Tulane) from Fractyl and Jaguar Gene Therapy; has received consultant honoraria from Asahi, Bayer, Abbott, Boehringer Ingelheim, and Corcept; has stock or stock options in Mellitus Health, BRAVO4Health, Amgen, and Abbott; and has patents pending for BRAVO risk engine for predicting diabetes complications and PAX4 gene therapy for type 1 diabetes. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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