For adults with type 2 diabetes initiating second-line antidiabetic medications (ADM), cardiovascular risk is increased with use of sulfonylureas or basal insulin versus newer ADM classes, according to a study published online Dec. 21 in JAMA Network Open.

Matthew J. O'Brien, M.D., from the Northwestern University Feinberg School of Medicine in Chicago, and colleagues examined the correlation of second-line ADM classes with major adverse cardiovascular events in a cohort of 132,737 insured adults with type 2 diabetes. Participants started therapy with a second-line ADM after taking metformin alone or no prior ADM.

There were 3,480 incident cardiovascular events during 169,384 person-years of follow-up. The researchers found that the risk for composite cardiovascular events was lower after patients started glucagon-like peptide-1 (GLP-1) receptor agonists versus dipeptidyl peptidase 4 (DPP-4) inhibitors, after adjustment for patient, prescriber, and health plan characteristics (hazard ratio, 0.78); this finding was not significant in all sensitivity analyses. Cardiovascular event rates were not significantly different after patients started treatment with sodium-glucose cotransporter 2 (SGLT-2) inhibitors and thiazolidinediones versus DPP-4 inhibitors. A higher comparative risk for cardiovascular events was seen after patients started treatment with sulfonylureas or basal insulin (hazard ratios, 1.36 and 2.03, respectively) versus DPP-4 inhibitors.

"Clinicians may consider prescribing GLP-1 receptor agonists, DPP-4 inhibitors, or SGLT-2 inhibitors more routinely after metformin rather than sulfonylureas or basal insulin," the authors write.

Two authors disclosed financial ties to the biopharmaceutical industry.

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