Objective: Racial and rural disparities exist in the adoption of newer antidiabetic agents, including SGLT2 inhibitors. We aimed to evaluate whether the effectiveness of SGLT2 inhibitors varied across race/ethnicity and rural/urban areas.

Methods: Using claims data from 15% samples of national Medicare beneficiaries, we identified individuals who had type 2 diabetes and initiated SGLT2 inhibitors or DPP4 inhibitors (as the active control) between 1/1/2017-12/31/2018. Cohort entry was the day of the first filled prescription of any SGLT2 inhibitors or DPP4 inhibitors, defined as no use of either in the prior year. The outcome was hospitalization for heart failure (HHF) . Inverse probability treatment weighting (IPTW) Cox regressions were applied, controlling for pre-exposure covariates. IPTW models were fitted separately across subgroups.

Results: Cohort, mean age was 72 (SD 10) , 53% were women and 2.2% (2,577 / 116,751) experienced HHF over a median follow up of 363 days. Compared with DPP4 inhibitors, SGLT2 inhibitors were associated with a lower risk of HHF (HR, 0.73; CI, 0.65-0.80) . In the subgroup analyses, the beneficial effect of SGLT2 inhibitors vs. DPP4 inhibitors were comparable across non-Hispanic White (HR, 0.77; CI, 0.68-0.87) , non-Hispanic Black (HR, 0.67; CI, 0.49-0.91) and Hispanic (HR, 0.68; CI, 0.50-0.92) groups. SGLT2 inhibitors associated decreased risk of HHF was only seen in individuals living in urban areas (HR, 0.69; CI, 0.61-0.78) but not rural areas (HR, 0.95; CI, 0.76-1.19) .

Conclusion: Use of SGLT2 inhibitors, vs. DPP4 inhibitors, was associated with a lower risk of HHF and the effectiveness were comparable across racial and ethnics groups. However, SGLT2 inhibitors’ HHF benefit appeared to have been attenuated in those living in rural areas. Future studies are warranted to understand the mechanisms underlying the potential rural-urban disparities in treatment outcomes.


J.Guo: None. Y.Li: None. J.Bian: None. D.T.Lackland: None. S.Kimmel: Other Relationship; Janssen Pharmaceuticals, Inc. D.Schatz: Advisory Panel; Abbott Diabetes, Medtronic. A.G.Winterstein: Consultant; Genentech, Inc., Research Support; Merck & Co., Inc.

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