Empagliflozin benefit in older adults looked consistent across subgroups

Design

Propensity-matched cohort study using Medicare claims, 2014 to 2020

Population

Adults aged 65 and over with type 2 diabetes starting empagliflozin vs DPP-4 inhibitors or GLP-1 receptor agonists

Primary outcome

MACE, heart failure hospitalisation and all-cause mortality

Effect

vs DPP-4 inhibitors: MACE HR 0.77, HHF HR 0.72, mortality HR 0.66; vs GLP-1 RA: HHF HR 0.88 (0.81 to 0.95)

EMPRISE is a real-world programme using US Medicare claims for adults aged 65 and over with type 2 diabetes who started empagliflozin, compared after propensity matching with people starting a DPP-4 inhibitor or a GLP-1 receptor agonist.

Against DPP-4 inhibitors, empagliflozin was associated with lower major adverse cardiovascular events (HR 0.77), heart failure hospitalisation (HR 0.72) and all-cause mortality (HR 0.66). Against GLP-1 receptor agonists, it was associated with fewer heart failure hospitalisations (HR 0.88, 0.81 to 0.95). No heterogeneity appeared by sociodemographic factors. Absolute benefit was larger in people with existing cardiovascular disease, and numerically larger at age 75 and over.

These estimates come from claims data and rest on measured confounders only. They are reassuring about generalisability to older and more disadvantaged groups, but they do not replace trial evidence.

• Empagliflozin was linked to fewer heart failure admissions than both DPP-4 inhibitors (HR 0.72) and GLP-1 receptor agonists (HR 0.88).
• Results were similar across age, sex, race and socioeconomic groups.
• Absolute benefit was larger in people with established cardiovascular disease.
• Age alone is not a reason to withhold an SGLT2 inhibitor, but check volume status, renal function and genital infection risk.
• Cost and access in India remain separate considerations from this US data.

Why it matters

It addresses the usual worry that trial results may not carry to older, more vulnerable patients.

Don't overread it

A claims analysis can only adjust for what is recorded, so unmeasured differences between drug users may remain.

The statistics, in plain English

The hazard ratio gives the relative reduction; the incidence rate difference (for example -10.3 for cardiovascular events against DPP-4 inhibitors, per the study's rate units) gives the absolute reduction. Absolute differences are what matter for deciding who gains most, which is why the benefit looked larger in people who already had cardiovascular disease.

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