• Bin Hong, Sungho Bea, Hwa Yeon Ko, Woo Jung Kim, Young Min Cho, and Ju-Young Shin.
• School of Pharmacy, Sungkyunkwan University, Suwon, South Korea (B.H., H.Y.K.).
• Ann. Intern. Med. 2024 Oct 1; 177 (10): 131913291319-1329.

BackgroundBoth sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) may have neuroprotective effects in patients with type 2 diabetes (T2D). However, their comparative effectiveness in preventing dementia remains uncertain.ObjectiveTo compare the risk for dementia between SGLT2 inhibitors and dulaglutide (a GLP-1 RA).DesignTarget trial emulation study.SettingNationwide health care data of South Korea obtained from the National Health Insurance Service between 2010 and 2022.PatientsPatients aged 60 years or older who have T2D and are initiating treatment with SGLT2 inhibitors or dulaglutide.MeasurementsThe primary outcome was the presumed clinical onset of dementia. The date of onset was defined as the year before the date of dementia diagnosis, assuming that the time between the onset of dementia and diagnosis was 1 year. The 5-year risk ratios and risk differences comparing SGLT2 inhibitors with dulaglutide were estimated in a 1:2 propensity score-matched cohort adjusted for confounders.ResultsOverall, 12 489 patients initiating SGLT2 inhibitor treatment (51.9% dapagliflozin and 48.1% empagliflozin) and 1075 patients initiating dulaglutide treatment were included. In the matched cohort, over a median follow-up of 4.4 years, the primary outcome event occurred in 69 participants in the SGLT2 inhibitor group and 43 in the dulaglutide group. The estimated risk difference was -0.91 percentage point (95% CI, -2.45 to 0.63 percentage point), and the estimated risk ratio was 0.81 (CI, 0.56 to 1.16).LimitationResidual confounding is possible; there was no adjustment for hemoglobin A1c levels or duration of diabetes; the study is not representative of newer drugs, including more effective GLP-1 RAs; and the onset of dementia was not measured directly.ConclusionUnder conventional statistical criteria, a risk for dementia between 2.5 percentage points lower and 0.6 percentage point greater for SGLT2 inhibitors than for dulaglutide was estimated to be highly compatible with the data from this study. However, whether these findings generalize to newer GLP-1 RAs is uncertain. Thus, further studies incorporating newer drugs within these drug classes and better addressing residual confounding are required.Primary Funding SourceMinistry of Food and Drug Safety of South Korea.

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