TY - JOUR
T1 - Second-Line Therapy for Type 2 Diabetes Management
T2 - The Treatment/Benefit Paradox of Cardiovascular and Kidney Comorbidities
AU - McCoy, Rozalina G.
AU - Van Houten, Holly K.
AU - Karaca-Mandic, Pinar
AU - Ross, Joseph S.
AU - Montori, Victor M.
AU - Shah, Nilay D.
N1 - Funding Information:
Funding. This effort was funded by the National Institutes of Health (NIH) National Institute of Diabetes and Digestive and Kidney Diseases grant K23DK114497 (R.G.M) and Agency for Healthcare Research and Quality’s (AHRQ) Comparative Health System Performance Initiative grants 1U19HS024075 (N.D.S.) and R01HS025164 (P.K.-M., N.D.S.). In the past 36 months, R.G.M. received research support through NIDDK (R03DK114497, P30DK111024) and AARP (Quality Measure Innovation Grant). In the past 36 months, N.D.S. received research support through Mayo Clinic from the U.S. Food and Drug Administration (FDA) to establish the Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation (CERSI) program (U01FD005938), the Centers of Medicare and Medicaid Innovation under the Transforming Clinical Practice Initiative (TCPI), AHRQ (R01HS025402, R03HS025517), the National Heart, Lung and Blood Institute (NHLBI) of the NIH (R56HL130496, R01HL131535), the National Science Foundation, and the Patient Centered Outcomes Research Institute (PCORI) to develop a Clinical Data Research Network (LHSNet). In the past 36 months, S.J.R. has received research support from the U.S. FDA to develop methods for postmarket surveillance of medical devices (U01FD004585), FDA to establish the Yale-Mayo Clinic CERSI program (U01FD005938), from AHRQ (R01HS022882), NHLBI (R01HS025164), and from the Laura and John Arnold Foundation to establish the Good Pharma Scorecard at Bioethics International. P.K.-M. serves as the principal investigator to several grants on prescription drug studies from NIH National Institute on Aging (P01AG005842), NHLBI (R56HL130496), and the American Cancer Society (131611-RSGI-17-154-01-CPHPS).
Funding Information:
This effort was funded by the National Institutes of Health (NIH) National Institute of Diabetes and Digestive and Kidney Diseases grant K23DK114497 (R.G.M) and Agency for Healthcare Research and Quality’s (AHRQ) Comparative Health System Performance Initiative grants 1U19HS024075 (N.D.S.) and R01HS025164 (P.K.-M., N.D.S.). In the past 36 months, R.G.M. received research support through NIDDK (R03DK114497, P30DK111024) and AARP (Quality Measure Innovation Grant). In the past 36 months, N.D.S. received research support through Mayo Clinic from the U.S. Food and Drug Administration (FDA) to establish the Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation (CERSI) program (U01FD005938), the Centers of Medicare and Medicaid Innovation under the Transforming Clinical Practice Initiative (TCPI), AHRQ (R01HS025402, R03HS025517), the National Heart, Lung and Blood Institute (NHLBI) of the NIH (R56HL130496, R01HL131535), the National Science Foundation, and the Patient Centered Outcomes Research Institute (PCORI) to develop a Clinical Data Research Network (LHSNet). In the past 36 months, S.J.R. has received research support from the U.S. FDA to develop methods for postmarket surveillance of medical devices (U01FD004585), FDA to establish the Yale-Mayo Clinic CERSI program (U01FD005938), from AHRQ (R01HS022882), NHLBI (R01HS025164), and from the Laura and John Arnold Foundation to establish the Good Pharma Scorecard at Bioethics International. P.K.-M. serves as the principal investigator to several grants on prescription drug studies from NIH National Institute on Aging (P01AG005842), NHLBI (R56HL130496), and the American Cancer Society (131611-RSGI-17-154-01-CPHPS). Study contents are the sole responsibility of the authors and do not necessarily represent the official views of the NIH.
Publisher Copyright:
© 2021 by the American Diabetes Association.
PY - 2021/10
Y1 - 2021/10
N2 - OBJECTIVE 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. RESEARCH DESIGN AND METHODS 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. RESULTS 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. CONCLUSIONS 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.
AB - OBJECTIVE 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. RESEARCH DESIGN AND METHODS 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. RESULTS 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. CONCLUSIONS 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.
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U2 - 10.2337/DC20-2977
DO - 10.2337/DC20-2977
M3 - Article
C2 - 34348996
AN - SCOPUS:85127320814
SN - 1935-5548
VL - 44
SP - 2302
EP - 2311
JO - Diabetes Care
JF - Diabetes Care
IS - 10
ER -