Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
Department of Statistics, National Cheng Kung University, Tainan, Taiwan.
JAMA Netw Open. 2024 Oct 1;7(10):e2441765. doi: 10.1001/jamanetworkopen.2024.41765.
Cardiovascular disease (CVD) can be recurrent during type 2 diabetes (T2D) progression in this aging population. The effectiveness of sodium-glucose cotransporter 2 inhibitor (SGLT2i) therapy on total (ie, first and subsequent) CVD among patients with T2D in clinical practice remains uncertain.
To analyze the comparative association of SGLT2i vs dipeptidyl peptidase 4 inhibitor (DPP4i) therapy with total CVD among patients with T2D in clinical practice.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used electronic medical records at the National Cheng Kung University Hospital, a leading medical center in Taiwan, from 2015 through 2021. Adult patients with T2D who initiated first use of the study drugs from 2016 through 2019, with up to 6 years of follow-up, were identified.
The primary outcomes included total composite CVD events and individual CVD subtypes (ie, atrial fibrillation, coronary heart disease, heart failure, stroke, myocardial infarction, and transient ischemic attack). A shared frailty model analysis was used to assess the association of treatment with repeat CVD events. Data from patients at high risk for CVD recurrence were further analyzed. Data were analyzed from September 1, 2022, to December 31, 2023.
Overall, 8384 patients with T2D were identified (mean [SD] age, 63.7 [12.4] years; 4645 [55.4%] male). A total of 1632 propensity score-matched pairs of SGLT2i (mean [SD] age, 57.8 [12.0] years; 673 [41.2%] female and 959 [58.8%] male) and DPP4i (mean [SD] age, 58.2 [12.9] years; 655 [40.1%] female and 977 [59.9%] male) users were included. SGLT2i was associated with reduced total CVD risk vs DPP4i therapy (hazard ratio [HR], 0.82 [95% CI, 0.69-0.98]) but not the first CVD event (with the use of SGLT2i therapy were more prominent for patients at high risk of CVD (ie, HR, 0.70 [95% CI, 0.62-0.80] for individuals with estimated glomerular filtration rate lower than 60 mL/min/1.73 m2; HR, 0.70 [95% CI, 0.64-0.78]; for individuals having any diabetes-related complications; and HR, 0.72 [95% CI, 0.65-0.80] for individuals with a history of CVD) compared with the overall cohort. Among patients at high risk of CVD, greater reduced total CVD burden associated with SGLT2i therapy was observed for women vs men (eg, HR, 0.59 [95% CI, 0.49-0.72] in the subgroup with CVD history).
In this cohort study of patients with T2D, the use of SGLT2is vs DPP4is was associated with reduced total cardiovascular burden, suggesting that long-term use of this therapy may optimize treatment benefit among patients with chronic CVD. The SGLT2i-associated benefit among patients with high risk of CVD encourages the prioritization of SGLT2i use for these vulnerable individuals.
在这个老龄化人口中，2 型糖尿病（T2D）进展期间心血管疾病（CVD）可能会反复发生。钠-葡萄糖共转运蛋白 2 抑制剂（SGLT2i）治疗在临床实践中对 T2D 患者首次和随后的总（即首次和随后）CVD 的有效性仍不确定。
分析 SGLT2i 与二肽基肽酶 4 抑制剂（DPP4i）治疗在 T2D 患者中的全因 CVD 的比较相关性。
设计、设置和参与者：这是一项回顾性队列研究，使用了台湾国立成功大学医院的电子病历，该医院是台湾的一家领先医疗中心，从 2015 年到 2021 年。从 2016 年到 2019 年，确定了首次使用研究药物的 T2D 成年患者，随访时间长达 6 年。
主要结果包括总复合 CVD 事件和个体 CVD 亚型（即心房颤动、冠心病、心力衰竭、中风、心肌梗死和短暂性脑缺血发作）。使用共享脆弱模型分析评估治疗与重复 CVD 事件的关联。对高 CVD 复发风险患者的数据进行了进一步分析。数据于 2022 年 9 月 1 日至 2023 年 12 月 31 日进行分析。
共有 8384 例 T2D 患者被确定（平均[SD]年龄，63.7[12.4]岁；4645[55.4%]男性）。共匹配了 1632 对倾向评分 SGLT2i（平均[SD]年龄，57.8[12.0]岁；653[41.2%]女性和 959[58.8%]男性）和 DPP4i（平均[SD]年龄，58.2[12.9]岁；655[40.1%]女性和 977[59.9%]男性）使用者。与 DPP4i 治疗相比，SGLT2i 治疗与降低总 CVD 风险相关（风险比[HR]，0.82[95%CI，0.69-0.98]），但与首次 CVD 事件无关（SGLT2i 治疗在 CVD 高风险患者中更为显著（即，对于估计肾小球滤过率低于 60 mL/min/1.73 m2 的个体，HR 为 0.70[95%CI，0.62-0.80]；对于有任何糖尿病相关并发症的个体，HR 为 0.70[95%CI，0.64-0.78]；对于有 CVD 病史的个体，HR 为 0.72[95%CI，0.65-0.80]）与总体队列相比。在 CVD 高风险患者中，与 SGLT2i 治疗相关的总 CVD 负担降低与女性有关（例如，在有 CVD 病史的亚组中，HR 为 0.59[95%CI，0.49-0.72]）。
在这项 T2D 患者的队列研究中，与 DPP4i 相比，使用 SGLT2i 与降低总心血管负担相关，表明长期使用这种治疗可能会优化慢性 CVD 患者的治疗效果。在 CVD 高风险患者中，SGLT2i 的获益鼓励优先考虑使用 SGLT2i 治疗这些脆弱人群。
