Although clinical trials have demonstrated favorable cardiovascular and kidney effects from use of sodium-glucose cotransporter 2 (SGLT2) inhibitors, clinicians appear to be underprescribing these drugs to patients with chronic kidney disease (CKD), a real-world study indicates.
The Kidney Disease Improving Global Outcomes (KDIGO) guideline recommends initiating an SGLT2 inhibitor (eg, canagliflozin, empagliflozin, and dapagliflozin) in patients who have CKD with an estimated glomerular filtration rate (eGFR) of 30 mL/min/1.73 m2 or higher and albuminuria with or without diabetes. An SGLT2 inhibitor may be continued for kidney protection if the eGFR dips below 30 mL/min/1.73 m2.
The medications increase urinary sodium and glucose excretion. The CREDENCE and DAPA-CKD trials found decreased risk for CKD progression and cardiovascular benefits from these drugs. There is not enough evidence to support the use of an SGLT2 inhibitor in patients who have CKD without albuminuria, diabetes, or heart failure.
In a study of 72,240 patients with nondialysis-dependent CKD stage 3-5 (44% male; 85% White) within the CKD registry of the Mass General Brigham health care system, 22,653 (31%) had diabetes and 49,587 (69%) did not. In March 2021, an SGLT2 inhibitor was prescribed to only 6% of those with diabetes and 0.3% of those without diabetes, Min Zhuo, MD, MPH, of Brigham and Women’s Hospital and Harvard Medical School in Boston, Massachusetts, and colleagues reported in Kidney360. The investigators noted that less than 10% of patients in the CKD registry saw a nephrologist.
In multivariable analyses, younger age, male sex, Black race, heart failure, and at least 1 cardiologist visit in the prior year were significantly associated with increased odds of an SGLT2 inhibitor prescription in both the diabetes and nondiabetes cohorts. Use of cardiovascular medications, such as renin angiotensin aldosterone system (RAAS) inhibitors, also were significantly associated with increased odds of an SGLT2 inhibitor prescription.
Among patients with diabetes, advancing CKD stage significantly decreased the odds of an SGLT2 inhibitor prescription, whereas urine dipstick test and at least 1 specialist visit in the prior year increased the odds of an SGLT2 inhibitor prescription. These same factors did not significantly correlate with SGLT2 inhibitor use in patients without diabetes.
“Despite the well-demonstrated benefits of SGLT-2i in slowing kidney progression and reducing cardiovascular death, the adaption of these novel agents remained low in the CKD population, particularly among patients without diabetes,” Dr Zhuo’s team wrote. “Population-level interventions to increase SGLT-2i utilization and improve outcomes in patients with CKD are urgently needed to impact the incidence of ESKD.”
The investigators discussed several barriers to SGLT2 inhibitor uptake and possible remedies. Proteinuria testing can be increased with electronic health record-based registries that identify gaps in care. Primary care providers and nephrologists unfamiliar with the SGLT2 inhibitor medical class and its clinical applications may benefit from continuous medical education. Suboptimal access to specialists can expand with use of telemedicine and allied health professionals for specific consultation on SGLT2 inhibitors. A remote care management program that is algorithm-based, pharmacist led, and nephrologist supported could also aid prescription. Finally, advocacy with policymakers, payers, and pharmaceutical companies can lower costs of SGLT2 inhibitors and make these health-saving drugs more affordable.
Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Zhuo M, Li J, Buckley LF, et al. Prescribing patterns of sodium-glucose cotransporter-2 inhibitors in patients with chronic kidney disease: a cross-sectional registry analysis. Kidney360. Published online January 19, 2022. doi:10.34067/KID.0007862021