Emulating randomized controlled trials of long-acting insulins and cardiovascular events using real-world data for patients with type 2 diabetes

AimsRandomized controlled trials (RCTs) have high internal validity but often have limited generalizability. To our knowledge, there are no studies examining potential differences between RCTs and real-world data in patient characteristics and risk of major adverse cardiovascular events (MACE) among patients with type 2 diabetes mellitus (T2DM) treated with long-acting insulin analogues. MethodsWe emulated the DEVOTE trial of insulin degludec vs glargine among patients with T2DM using data from the United Kingdoms Clinical Practice Research Datalink. DEVOTE eligible and ineligible subpopulations were created. Cox proportional hazards models with inverse probability of treatment weighting were used to estimate hazard ratios (HRs) and corresponding confidence intervals (CIs) for MACE comparing new users of insulin degludec to new users of insulin glargine overall and in the eligible/ineligible subpopulations. ResultsThere were 10,430 patients in the overall population, 5,280 in the DEVOTE eligible population, and 5,150 in the DEVOTE ineligible population. The overall (HR: 1.36, 95% CI: 0.83, 1.86) and DEVOTE eligible populations (HR: 1.07, 95% CI: 0.63, 1.58) were compatible with findings from the DEVOTE trial (HR: 0.91, 95% CI: 0.78, 1.06) for the risk of MACE. Due to a low number of events the DEVOTE ineligible population had deviations in point estimates and wider CIs (HR: 2.19, 95% CI: 0.30, 3.83). ConclusionThe risk of MACE among patients with T2DM newly prescribed insulin degludec compared to insulin glargine was consistent between the overall population and the DEVOTE eligible subpopulation, while the DEVOTE ineligible population had discrepant point estimates. Twitter SummaryOur study emulated the DEVOTE trial using RWD. Half of the RWD population would be eligible for the trial. RWD and RCTs had compatible effect estimate for risk of major cardiovascular outcomes.