New data show that sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like-peptide-1-receptor agonists (GLP-1-RA) do not largely differ in their effectiveness to prevent myocardial infarction or stroke, regardless of whether type-2 diabetes patients have established cardiovascular disease at the time of drug initiation.

However, SGLT2i offer consistent reductions in the risk of hospitalization for heart failure in patients with and without cardiovascular disease, although the absolute decrease in risk appears to be substantially greater among patients with cardiovascular disease.

"These findings have important implications with respect to clinical decision making," Dr. Elisabetta Patorno of Brigham and Women's Hospital and Harvard Medical School, in Boston, told Reuters Health by email.

"Because the two classes are equally effective for stroke and myocardial infarction, but the SGLT2i are superior for heart failure, when considered in aggregate, SGLT2i are likely to prevent more of these adverse cardiovascular events than GLP-1-RA," she said.

In the last few years, large randomized placebo-controlled trials have provided evidence that GLP1-RA and SGLT2i can lead to clinically important reductions in cardiovascular events and mortality in patients with type-2 diabetes, Dr. Patorno and her colleagues note in Annals of Internal Medicine.

Current guidelines have adopted this evidence and now recommend that physicians consider either SGLT2i or GLP-1-RA as therapies for patients with established cardiovascular disease.

"However, no randomized clinical trials exist to allow the direct comparison of GLP-1RA with SGLT2i for cardiovascular event prevention in patients with diabetes, which means that clinicians and patients have to decide which drug to use without any studies comparing the two classes head-to-head in patients with and without established cardiovascular disease. Our study aimed to address this gap in evidence," Dr. Patorno told Reuters Health.

The researchers analyzed data from Medicare and two U.S. commercial claims databases for roughly 370,000 patients with type-2 diabetes, including more than 100,000 with established cardiovascular disease.

They found no difference in the risk for the primary outcome of hospitalization for MI or stroke when starting SGLT2i or GLP-1-RA.

When stratified by cardiovascular-disease history at baseline, rates of MI and stroke were similar in patients without CVD prescribed SGLT2i or GLP-1-RA therapy, but there was a 10% decrease in risk among patients with CVD starting a SGLT2i compared with a GLP-1-RA (hazard ratio, 0.90; 95% confidence interval, 0.82 to 0.98).

Starting SGLT2i versus GLP-1 RA therapy was associated with about a 30% lower risk for heart-failure hospitalization in all patients (HR, 0.70; 95 CI, 0.64 to 0.77), regardless of CVD status at baseline, but this benefit was substantially greater among patients with heart disease.

There were no meaningful differences in the risk for all-cause mortality in those who initiated SGLT2i versus GLP-1-RA therapy, although a decrease in risk was observed in patients with CVD who received SGLT2i therapy.

These real-world comparative cardiovascular effectiveness data in diabetes patients with and without CVD may help clinicians and patients choose between the two drug classes, the authors say.

SOURCE: https://bit.ly/3kN27YN Annals of Internal Medicine, online September 27, 2021.