Aims/hypothesis

The aim of this study was to investigate racial and ethnic disparities in the use of sodium–glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor antagonists (GLP-1RAs) among older adults with type 2 diabetes and cardiorenal conditions.

Methods

Using Medicare fee-for-service data (2013–2019), this retrospective cohort study identified older adults (≥65 years) with type 2 diabetes initiating second-line therapies (SGLT2is, GLP1-RAs, dipeptidyl peptidase-4 inhibitors [DPP4is] and sulfonylureas [SUs]) with (1) heart failure (HF), (2) atherosclerotic cardiovascular disease (ASCVD), (3) chronic kidney disease (CKD) and (4) no recorded cardiorenal conditions. Participants were classified as non-Hispanic White, non-Hispanic Black and Hispanic. Multinomial regressions, adjusting for sociodemographic, clinical and county-level characteristics, were used to model the odds of initiating SGLT2is or GLP-1RAs within each cohort.

Results

Black participants with HF, ASCVD, CKD or no recorded cardiorenal conditions had 35% (adjusted OR 0.65 [95% CI 0.61, 0.68]), 33% (0.67 [0.64, 0.69]), 32% (0.68 [0.64, 0.72]) and 24% (0.76 [0.74, 0.79]) lower odds of initiating SGLT2is, respectively, than White participants. Disparities ameliorated from 50–60% lower odds in 2013 to 17–18% in 2019. Similar patterns were observed for GLP-1RA uptake among Black participants. By contrast, Hispanic participants had similar odds of SGLT2i initiation in the HF and CKD cohorts as White participants, but 6% (0.94 [0.91, 0.98]) lower odds in the ASCVD cohort. Notable disparities for Hispanic participants compared with White participants were observed for GLP-1RA uptake in the HF, ASCVD, CKD and no cardiorenal conditions cohorts: 11% (0.89 [0.84, 0.94]), 16% (0.84 [0.81, 0.87]), 16% (0.84 [0.80, 0.89]) and 25% (0.75 [0.72, 0.78]) lower odds, respectively. Participants had greater odds than White participants of initiating DPP4is, which confer no cardiorenal benefits, across all cohorts (HF 1.25 [1.19, 1.31]; ASCVD 1.36 [1.32, 1.40]; CKD 1.32 [1.26, 1.38). Adjustment for social determinants of health did not meaningfully change the study findings.

Conclusions/interpretation

Compared with White participants, disparities in the uptake of SGLT2is were evident for Black participants, and in the uptake of GLP-1RAs for both Black and Hispanic participants. This study highlights how type 2 diabetes management is evolving, while underscoring historical imbalances that have shown signs of abatement.

Graphical Abstract

中文翻译：

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2013-2019 年患有 2 型糖尿病和心力衰竭、动脉粥样硬化性心血管疾病和慢性肾病的 Medicare 受益人在接受 SGLT2is 和 GLP-1RAs 方面的种族和民族差异

 目标/假设

本研究的目的是调查患有 2 型糖尿病和心肾病的老年人在使用钠-葡萄糖协同转运蛋白 2 抑制剂 （SGLT2is） 和胰高血糖素样肽-1 受体拮抗剂 （GLP-1RAs） 的种族和民族差异。

 方法

这项回顾性队列研究使用医疗保险按服务收费数据（2013-2019 年），确定了开始二线治疗（SGLT2is、GLP1-RAs、二肽基肽酶-4 抑制剂 [DPP4is] 和磺脲类药物 [SUs]）的 2 型糖尿病老年人（≥65 岁）与 （1） 心力衰竭 （HF），（2） 动脉粥样硬化性心血管疾病 （ASCVD），（3） 慢性肾病 （CKD） 和 （4） 没有心肾疾病记录。参与者被分为非西班牙裔白人、非西班牙裔黑人和西班牙裔。根据社会人口学、临床和县级特征进行调整的多项回归用于模拟每个队列中启动 SGLT2is 或 GLP-1RAs 的几率。

 结果

患有 HF、ASCVD、CKD 或无心肾疾病记录的黑人参与者的开始 SGLT2is 的几率分别比白人参与者低 35% （校正 OR 0.65 [95% CI 0.61， 0.68]）、33% （0.67 [0.64， 0.69]）、32% （0.68 [0.64， 0.72]）和 24% （0.76 [0.74， 0.79]）。差距从 2013 年的 50-60% 降低到 2019 年的 17-18%。在黑人参与者中观察到 GLP-1RA 摄取的类似模式。相比之下，西班牙裔参与者在 HF 和 CKD 队列中与白人参与者发生 SGLT2i 的几率相似，但在 ASCVD 队列中低 6% （0.94 [0.91， 0.98]）。在 HF、ASCVD、CKD 和无心肾疾病队列中观察到西班牙裔参与者与白人参与者在 GLP-1RA 摄取方面的显著差异：分别低 11% （0.89 [0.84， 0.94]）、16% （0.84 [0.81， 0.87]）、16% （0.84 [0.80， 0.89]）和 25% （0.75 [0.72， 0.78]）。在所有队列中，参与者启动 DPP4is 的几率高于白人参与者，DPP4is 没有带来心肾益处 （HF 1.25 [1.19， 1.31];ASCVD 1.36 [1.32， 1.40];慢性肾病 1.32 [1.26， 1.38]。对健康的社会决定因素的调整并没有有意义地改变研究结果。

结论/解释

与白人参与者相比，黑人参与者对 SGLT2is 的摄取存在明显差异，黑人和西班牙裔参与者对 GLP-1RAs 的摄取存在明显差异。这项研究强调了 2 型糖尿病管理是如何演变的，同时强调了已显示出缓解迹象的历史失衡。

 图形摘要