Purpose <p>While SGLT-2i and GLP-1RA show cardiorenal benefits, their comparative efficacy in elderly type 2 diabetes mellitus (T2DM) patients remains uncertain. This study aimed to compare SGLT-2i and GLP-1RA on cardiovascular and renal outcomes in elderly T2DM patients.</p> Methods <p>This retrospective study analyzed 1,015 propensity score-matched elderly T2DM patients (SGLT-2i group: n = 583; GLP-1RA group: n = 432). Medical records were collected to assess cardiovascular/renal outcomes, glycemic parameters [(fasting plasma glucose (FPG), 2-h postprandial blood glucose (2hPBG), homeostatic model assessment of insulin resistance (HOMA-IR), and&#xa0;hemoglobin A1c (HbA1c)], body mass index<b> (</b>BMI), and adverse reactions. A Cox regression model was constructed to analyze the impact of SGLT-2i and GLP-1RA on 3-point major adverse cardiovascular events (3P-MACE: non-fatal myocardial infarction, stroke, and cardiovascular death) and adverse renal outcomes (persistent decline in eGFR by 40%, end-stage renal disease, or death due to renal disease) across subgroups.</p> Results <p>The two groups were similar in baseline clinical characteristics. The risk of 3P-MACE was not markedly different between the SGLT-2i and GLP-1RA groups (<i>P</i> = 0.071), while SGLT-2i demonstrated a superior performance in reducing the risk of composite adverse renal outcomes (<i>P</i> = 0.014). Both groups achieved significant glycemic improvements and BMI reduction at 24&#xa0;months post-treatment (all <i>P</i> &lt; 0.05), with greater BMI reduction in GLP-1RA (<i>P</i> &lt; 0.05). The two groups did not differ markedly in overall adverse events (<i>P</i> &gt; 0.05). No marked differences were found in 3P-MACE or adverse renal composite outcomes across the predefined subgroups (all <i>P</i> &gt; 0.05).</p> Conclusion <p>In elderly T2DM patients, SGLT-2i and GLP-1RA contributed to similar cardiovascular outcomes, but SGLT-2i was associated with a lower risk of composite adverse renal outcomes.</p>