Older Americans living with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD) saw fewer serious heart problems when starting once weekly semaglutide rather than dulaglutide.
In a new Medicare analysis presented at a scientific meeting, semaglutide users had a 23 percent lower rate of major adverse cardiovascular events (MACE) and a 26 percent lower risk of death compared with dulaglutide users, based on matched records from 58,336 patients.
The comparison was head to head in routine care and used methods that aim to mirror a randomized trial. This matters because older adults with multiple conditions are often underrepresented in traditional trials.
People over 65 carry a heavy burden of heart disease and diabetes. Their risks for heart attack, stroke, hospitalization, and death are high in absolute terms.
Trials prove whether a drug works under strict rules, but many older patients take several medicines and face day to day hurdles. Real world data can test how results hold up when life is messy.
Doctors also have to choose among drugs within the same class. Semaglutide and dulaglutide are both GLP-1 receptor agonists (GLP-1 RA) medicines, yet their benefits might not be identical in every outcome.
A direct comparison in the population most at risk helps close a real knowledge gap. That is the niche this analysis tries to fill.
The researchers used Medicare claims to compare new users of once-weekly semaglutide and dulaglutide who were at least 66 and had established cardiovascular disease. They matched patients 1 to 1 and followed them for about a year on average.
The design followed a target trial emulation approach, with propensity score matching and time to event modeling, to reduce bias while using observational data.
Outcomes included the standard three-point MACE (a measure combining the risk of heart attack, stroke, or cardiovascular death), a broader five-point MACE (an expanded measure that also includes hospitalization for unstable angina or heart failure), and all-cause death.
Semaglutide was associated with lower rates across those outcomes, including the 23 percent relative risk reduction in three-point MACE and the 26 percent lower risk of death. Event rates per 1,000 person years were lower for semaglutide on both composite outcomes.
Observational work does not prove causation, so the findings should be read as strong signals rather than final answers. Even so, the scale and focus on older adults make the data hard to ignore.
Earlier clinical trials showed that semaglutide reduced the likelihood of cardiovascular death, heart attack, and stroke compared to placebo, confirming its protective effect on major heart outcomes.
Dulaglutide also demonstrated benefits for blood sugar control and cardiovascular health, particularly among middle aged and older adults.
These earlier findings laid the groundwork for the new Medicare analysis, which provides a direct real world comparison of the two GLP 1 drugs in high risk older patients.
In older adults, absolute risks are high, so a modest relative reduction can translate into many prevented events. Fewer strokes and heart attacks mean fewer hospital stays, less disability, and longer lives.
The death finding deserves careful attention. A 26 percent lower risk of death over about one year is clinically meaningful if confirmed in other settings.
Semaglutide also showed lower rates on the broader five-point MACE that included unstable angina, heart failure hospitalization, and death. That pattern strengthens the overall signal.
Treatment choices in primary care and cardiology often happen under time pressure. Clear, comparative information like this can help those decisions be more confident.
Every medicine brings benefits and risks. The FDA label for semaglutide warns about thyroid C cell tumors in rodents, pancreatitis, gallbladder disease, and a retinopathy signal that needs monitoring in people with prior eye disease.
Nausea, vomiting, and diarrhea are the most common side effects and often show up during dose escalation. Clinicians usually titrate slowly and adjust other glucose lowering drugs to limit hypoglycemia risk.
Patients with planned anesthesia or deep sedation should tell their surgical teams about GLP 1 therapy. The label notes delayed stomach emptying and a small risk of aspiration during procedures.
People with a personal or family history of medullary thyroid carcinoma, or with MEN 2, should not use semaglutide. That contraindication is consistent across GLP 1 drugs in class labeling.
Kidney protection is part of the picture too. In the FLOW randomized trial, semaglutide cut the risk of key kidney outcomes and reduced major cardiovascular events by 18 percent.
It also lowered the risk of death from any cause by 20 percent in patients with diabetes and chronic kidney disease (CKD) – a long-term condition in which the kidneys gradually lose their ability to filter waste from the blood.
Those kidney results led to an expanded U.S. indication for semaglutide in adults with type 2 diabetes and chronic kidney disease. Clinicians now have evidence that spans glucose, heart, and kidney outcomes in high risk groups.
Replication of the Medicare comparison in other datasets will be important. Longer follow up and subgroup analyses, including those on background SGLT2 inhibitors or statins, would help translate the signals into practice.
Health systems and payers will also focus on absolute risk reductions and numbers needed to treat. That is where older adults stand to gain the most.
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