GLP-1 receptor agonists or SGLT2-inhibitors? Evaluation of a personalized treatment algorithm for individuals with type 2 diabetes: a registry-based cohort study.

The personalized treatment algorithm predicted 48% of individuals to have better ASCVD outcomes with GLP-1-RA and 52% with SGLT2-inhibitors.

• Study used data from the Diabetes Prospective Follow-up registry (Germany/Austria) in a multicenter, real-world setting.
• GLP-1-RA initiators: n=1433; SGLT2i initiators: n=2547.
• Non-fatal ASCVD events analyzed included myocardial infarction, angina, revascularization, stroke, transient ischemic attack, and peripheral artery disease.
• Dynamic weighted survival modeling was used to predict the optimal treatment for each individual.

GLP-1-RA-optimal individuals had a higher BMI, lower eGFR, and less history of ASCVD compared to SGLT2i-optimal individuals.

• Mean BMI was 37 kg/m² in GLP-1-RA-optimal individuals versus 31 kg/m² in SGLT2i-optimal individuals.
• Mean eGFR was 71 ml/min per 1.73 m² in GLP-1-RA-optimal individuals versus 93 ml/min per 1.73 m² in SGLT2i-optimal individuals.
• History of ASCVD was 9% in GLP-1-RA-optimal individuals versus 18% in SGLT2i-optimal individuals.
• Baseline characteristics used in the algorithm included age, sex, BMI, eGFR, HbA1c, diabetes duration, and history of ASCVD.

The predicted optimal treatment did not statistically significantly prolong the average time to a non-fatal ASCVD event compared to the suboptimal treatment.

• AFT parameter: 1.13; 95% CI: 0.83–1.56.
• Hazard ratio: 0.88; 95% CI: 0.64–1.21.
• This result was based on internal model validation.
• Neither confidence interval excluded the null, indicating no statistically significant benefit of algorithm-guided treatment selection.

Guidelines recommend both GLP-1 receptor agonists and SGLT2-inhibitors for individuals with type 2 diabetes at high risk of atherosclerotic cardiovascular disease.

• The study was motivated by the context of precision medicine and the goal of guiding the initial decision between these two therapy classes.
• The finding of no significant individualized benefit was described as 'consistent with the clinical equipoise reflected in current T2D treatment guidelines.'
• The study used an observational registry design rather than a randomized controlled trial.