Effects of antidiabetic drugs on mortality risks in individuals with type 2 diabetes: A prospective cohort study of UK Biobank participants
Elisa Araldi, Catherine R Jutzeler, Michael Ristow
doi:10.1101/2023.05.19.23290214
Objective: To investigate the mortality risk linked to prescription of different anti-diabetic medication classes. Design: Prospective population-based study. Setting: UK Biobank. Participants: 410 389 of the 502 536 participants in UK Biobank with covariate data, clinical and prescription records were included in the analyses, 43 610 of which had been diagnosed type 2 diabetes (T2D). A nearest neighbour covariate matching (NNCM) algorithm based on covariates with relevant effects on survival was applied to match cohorts of anti-diabetic medication class users to minimally differing control cohorts, either with a T2D diagnosis or without. Kaplan Meier estimates and Cox proportional models were used to evaluate survival differences and hazard ratio between drug classes and controls. Main outcome measures: All-cause mortality and causes of death. Results : 13667 (3.3%) individuals died during a median of 12.2 years of follow-up. After applying NNCM, participants with T2D on metformin (average hazard ratio 0.39, 95% confidence interval 0.31 to 0.49) or SGLT2I (average hazard ratio 0.58, 95% confidence interval 0.36 to 0.93) have an increased survival probability compared to matched individuals with T2D. When compared to matched individuals without T2D, the survival probability of individuals with T2D increases only if prescribed SGLT2I (average hazard ratio 0.31, 95% confidence interval 0.19 to 0.51). NNCMbased analysis of matched individuals with T2D on both SGLT2I and metformin versus metformin only reveals increased survival in the presence of SGLT2I (average hazard ratio 0.29, 95% confidence interval 0.09 to 0.91), also when compared to matched identical individuals without T2D (average hazard ratio 0.05, 95% confidence interval 0.01 to 0.19). All the other anti-diabetic drugs analyzed are either detrimental in prolonging lifespan (insulin, thiazolidinediones, and sulfonylureas), or have no effect (DPP4 inhibitors and GLP1 receptor agonists).
Conclusion: The use of the current first-line anti-diabetic treatment, metformin, or sodiumglucose cotransporter 2 inhibitors (SGLT2I) increases the survival probability compared to matched individuals with diabetes using other anti-diabetic drugs. Only individuals on SGLT2I experience increased survival when compared to individuals without T2D.
Contributors EA and MR designed the study. EA conducted the statistical analysis. EA and MR wrote the first draft. EA, CRJ, and MR critically revised the manuscript. MR is the guarantor of the manuscript and accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Ethics approval UK Biobank has obtained ethics approval from the North West Multi-Centre Research Ethics Committee (approval number: 11/NW/0382) and has obtained informed consent from all participants.
Transparency statement The manuscript's guarantor (MR) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.
Competing interests
All
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doi:10.1056/NEJMoa1504720DOI record:
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"abstract": "<jats:p>Objective: To investigate the mortality risk linked to prescription of different anti-diabetic medication classes. Design: Prospective population-based study. Setting UK Biobank. Participants: 410 389 of the 502 536 participants in UK Biobank with covariate data, clinical and prescription records were included in the analyses, 43 610 of which had been diagnosed type 2 diabetes (T2D). A nearest neighbour covariate matching (NNCM) algorithm based on covariates with relevant effects on survival was applied to match cohorts of anti-diabetic medication class users to minimally differing control cohorts, either with a T2D diagnosis or without. Kaplan Meier estimates and Cox proportional models were used to evaluate survival differences and hazard ratio between drug classes and controls. Main outcome measures: All-cause mortality and causes of death. Results: 13667 (3.3%) individuals died during a median of 12.2 years of follow-up. After applying NNCM, participants with T2D on metformin (average hazard ratio 0.39, 95% confidence interval 0.31 to 0.49) or SGLT2I (average hazard ratio 0.58, 95% confidence interval 0.36 to 0.93) have an increased survival probability compared to matched individuals with T2D. When compared to matched individuals without T2D, the survival probability of individuals with T2D increases only if prescribed SGLT2I (average hazard ratio 0.31, 95% confidence interval 0.19 to 0.51). NNCM-based analysis of matched individuals with T2D on both SGLT2I and metformin versus metformin only reveals increased survival in the presence of SGLT2I (average hazard ratio 0.29, 95% confidence interval 0.09 to 0.91), also when compared to matched identical individuals without T2D (average hazard ratio 0.05, 95% confidence interval 0.01 to 0.19). All the other anti-diabetic drugs analyzed are either detrimental in prolonging lifespan (insulin, thiazolidinediones, and sulfonylureas), or have no effect (DPP4 inhibitors and GLP1 receptor agonists). Conclusion: The use of the current first-line anti-diabetic treatment, metformin, or sodium-glucose cotransporter 2 inhibitors (SGLT2I) increases the survival probability compared to matched individuals with diabetes using other anti-diabetic drugs. Only individuals on SGLT2I experience increased survival when compared to individuals without T2D.</jats:p>",
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