McCoy Rozalina G, Van Houten Holly K, Karaca-Mandic Pinar, Ross Joseph S, Montori Victor M, Shah Nilay D
Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN.
Diabetes Care. 2021 Aug 4;44(10):2302-11. doi: 10.2337/dc20-2977.
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.
研究在心血管疾病、心力衰竭（HF）或肾病患者中，与二肽基肽酶4抑制剂（DPP-4i）相比，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）是否更优先用于已证实这些药物具有益处的患者，而DPP-4i的相应益处尚未得到证实。
我们回顾性分析了OptumLabs数据仓库中2型糖尿病成年患者的理赔数据，该数据仓库是一个匿名的商业保险和医疗保险优势受益人的数据库，这些患者在2016年至2019年间首次开始接受GLP-1RA、SGLT2i或DPP-4i治疗。使用多项逻辑回归，在调整人口统计学和其他临床因素后，我们研究了有心肌梗死（MI）、脑血管疾病、HF和肾病病史的患者开始使用GLP-1RA和SGLT2i与DPP-4i相比的相对风险比（RRR）。
我们确定了75395例开始使用GLP-1RA的患者、58234例开始使用SGLT2i的患者和91884例开始使用DPP-4i的患者。与没有这些疾病的患者相比，有MI、脑血管疾病或肾病病史的患者开始使用GLP-1RA而非DPP-4i的可能性较小（MI的RRR为0.83[95%CI 0.78-0.88]，脑血管疾病的RRR为0.77[0.74-0.81]，肾病的RRR为0.87[0.84-0.91]）。有HF或肾病的患者开始使用SGLT2i的可能性较小（HF的RRR为0.83[0.80-0.87]，肾病的RRR为0.57[0.55-0.60]）。这两类药物在非白人和老年患者中开始使用的可能性较小。
心血管疾病、HF和肾病患者从GLP-1RA和/或SGLT2i治疗中获益的可能性更大，但开始使用这些药物的可能性较小。解决这种治疗/益处悖论，这种悖论在非白人和老年患者中最为明显，可能有助于降低与这些疾病相关的发病率。
