Comparative Effectiveness and Safety of Four Second Line Pharmacological Strategies in Type 2 Diabetes Study

To perform an observational analysis to emulate a target trial (i.e., a hypothetical pragmatic trial that would have answered the causal question of interest) comparing the effectiveness and safety of sodium-glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide 1 receptor agonists (GLP-1RA), dipeptidyl peptidase-4 inhibitors (DPP-4i), and sulfonylureas (SU), at the class and individual agent level, in head-to-head comparisons in patients with type 2 diabetes (T2D).

Aim 1: (1a.) To evaluate the effectiveness of sodium-glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide 1 receptor agonists (GLP-1RA), dipeptidyl peptidase-4 inhibitors (DPP-4i), and sulfonylureas (SU), at the class and individual agent level, in head-to-head comparisons with respect to cardiovascular (CV) events, mortality, renal events, and other patient-centered outcomes (e.g., time spent at home), in patients with T2D and moderate baseline CV risk (event rate ≤3%/year). (1b.) To examine heterogeneity in treatment effects by age, race/ethnicity, gender, levels of CV risk, including high (≥4%/year) and low risk (\<2%/year), chronic kidney disease (CKD), frailty, and multimorbidity.

Aim 2: (2a.) To monitor and quantify the association of the initiation of SGLT2i, GLP-1RA, DPP-4i, or SU, at the class and individual agent level, with previously reported drug-related harms (e.g., diabetic ketoacidosis (DKA), fractures, amputations, pancreatitis, severe hypoglycemia). (2b.) To scan study data sources for signals of potential serious unanticipated drug-related adverse events, using a data-mining approach (tree-based scan statistics). (2c.) By using data generated in Aims 2a and 2b, to build treatment-specific outcome prediction models to identify individual patients' likelihood of drug-related harms, based on specific combinations of patient features.

Eligibility Criteria:
Inclusion Criteria:

* Age ≥ 18 years for Optum Cliniformatics, IBM Marketscan, CPRD, and VHA, and ≥ 65 years for Medicare FFS at cohort entry
* At least 12 months of continuous health plan enrollment (only claims) or registration with a general practitioner (CPRD) before and including cohort entry
* Diagnosis of T2D within 12 months before (or ever before in CPRD) and including cohort entry
* Low or moderate cardiovascular (CV) risk (≤3% risk of CV events/year) at cohort entry \*
* Metformin maintenance therapy, defined as 2 fills (or prescriptions in CPRD) of metformin monotherapy recorded within 6 months before and including cohort entry

Exclusion Criteria:

* Missing age or gender information
* Nursing care admission within 12 months before and including cohort entry (criteria ignored in CPRD)
* Diagnosis of type 1 diabetes within 12 months before and including cohort entry
* Diagnosis of secondary or gestational diabetes within 12 months before and including cohort entry
* Any insulin fill or prescription within 12 months before and including cohort entry
* Diagnosis of end stage renal disease (stage ≥ 5) within 12 months before and including cohort entry
* Diagnosis of acute or chronic pancreatitis within 12 months before and including cohort entry
* Diagnosis of cirrhosis or acute hepatitis within 12 months before and including cohort entry
* Diagnosis of MEN-2 within 12 months before and including cohort entry
* Recorded solid organ transplant code within 12 months before and including cohort entry
* Patients with recorded initiation of more than one agent within a comparator class at cohort entry