Which diabetes medicines protect the heart and kidneys?

What the review actually compared

The researchers searched for randomised trials lasting at least 24 weeks in adults with type 2 diabetes. They combined results from 816 trials involving 471,038 people and 13 different drug classes, comparing each medicine with standard treatment—the treatment someone was already receiving when a new drug was considered.

The standout medicines for heart and kidney protection

Compared with standard treatment, SGLT-2 inhibitors and GLP-1 receptor agonists reduced all-cause death. The review confirmed that both families also reduced cardiovascular death, non-fatal heart attacks, hospital admission for heart failure, and end-stage kidney disease. SGLT-2 inhibitors were among the most effective at reducing hospital admission for heart failure and were rated most effective for end-stage kidney disease; GLP-1 receptor agonists and finerenone probably helped too. Only GLP-1 receptor agonists convincingly reduced non-fatal stroke. Finerenone's evidence comes from people with chronic kidney disease, so its benefits are best understood in that group.

Side effects worth knowing

The harms were largely specific to each medicine family. SGLT-2 inhibitors were linked with genital infections. GLP-1 receptor agonists were linked with severe gastrointestinal side effects. Finerenone's main concern was too much potassium in the blood, serious enough to require hospital care. These are not minor footnotes; they help explain why the choice among heart- and kidney-protective options depends on a person's own risks.

Why a person's starting risk matters

The heart and kidney benefits are not the same size for everyone. The review estimated that absolute benefits of SGLT-2 inhibitors, GLP-1 receptor agonists, and finerenone vary depending on a person's baseline risks for cardiovascular and kidney outcomes. People who already have established cardiovascular disease, chronic kidney disease, or both are likely to gain the most, while the benefit may be smaller for someone with few such risks. This review also could not answer what happens when SGLT-2 inhibitors, GLP-1 receptor agonists, and finerenone are used together.