Advancements in Managing Chronic Kidney Disease: National Kidney Month Spotlight on SGLT2 Inhibitors

March 12, 2024 - Sara Bassi, PharmD

Advancements in Managing Chronic Kidney Disease
Advancements in Managing Chronic Kidney Disease

National Kidney Month is an opportune time to highlight recent advancements in managing chronic kidney disease (CKD), focusing on the promising data surrounding sodium-glucose cotransporter2 inhibitors (SGLT2i).  

Advancements in Managing Chronic Kidney Disease
Advancements in Managing Chronic Kidney Disease

The last few years have witnessed a paradigm shift in CKD management with the emergence of SGLT2i. Cardiovascular and renal benefits of SGLT2i were initially identified in cardiovascular outcomes trials (CVOTs), a requirement of the US Food and Drug Administration to evaluate the postmarketing cardiovascular safety profile of approved glucose-lowering type 2 diabetes (T2DM) drugs.2-5 The landmark DAPA-CKD and EMPA-KIDNEY trials have provided compelling evidence for the efficacy and safety of SGLT2i in reducing the risk of CKD progression, cardiovascular events, and mortality among patients with and without T2DM (including patients with immunoglobulin A nephropathy, focal segmental glomerulosclerosis, and heart failure).6-9 

 

In the DAPA-CKD trial, patients on dapagliflozin exhibited a 39% lower risk of the primary composite endpoint events (sustained decline in estimated glomerular filtration rate of at least 50%, end-stage kidney disease, or death from renal or cardiovascular causes) compared with patients on placebo (hazard ratio [HR], 0.61; 95% CI, 0.51-0.72; P<0.001).6 The EMPA-KIDNEY trial found that compared with patients on placebo, patients on empagliflozin had a 28% reduced risk of kidney disease progression or cardiovascular-related death (HR, 0.72; 95% CI, 0.64-0.82; P<0.001).7 

 

This growing body of evidence has positioned SGLT2i as a medication class with the potential to transform the CKD treatment landscape; however, its widespread adoption into clinical practice remains the next critical step in improving patient outcomes. Multiple large studies in the US have estimated that SGLT2i prescribing remains low in patients with T2DM and CKD, with only 2% to 12% of eligible patients receiving these therapies.10,11  

 

According to a survey by Singh et al, the most-common barriers to SGLT2i prescribing identified by nephrologists were the lack of insurance or high cost of SGLT2i (37%), lack of experience and comfort in prescribing SLGT2i (21%), and insufficient time or personnel to discuss the benefits and risks or to manage the side effects of SGLT2i during office visits (20%).10  The most common sources of information nephrologists use as guidance in prescribing SGLT2i are professional guidelines (30%), social media discussions (26%), and participation in major conferences (18%).12 

Advancements in Managing Chronic Kidney Disease
Advancements in Managing Chronic Kidney Disease

Effective medical communication strategies can help overcome barriers to SGLT2i uptake. Educational materials designed for healthcare professionals (HCPs) can focus on the platforms HCPs use to access information, such as conferences and social media campaigns.12 Considering the time constraints faced by HCPs, delivering education in concise, easily digestible segments can enhance engagement.

HCPs may receive practical guidance to support their discussions with patients regarding the advantages of SGLT2i in CKD, along with strategies for managing potential adverse effects. Educational strategies can highlight the importance of an interdisciplinary, collaborative, team-based approach to caring for patients with CKD.13 Furthermore, collaboration with treatment guideline committees can help ensure explicit recommendations regarding the utilization of SGLT2i in patients with CKD.13 

 

In summary, the latest progress in CKD care has emphasized the promise of SGLT2i in enhancing outcomes for individuals with CKD with and without T2DM. Despite these advancements, barriers to their widespread adoption persist, highlighting the need for tailored medical communication strategies.  

References

1. Centers for Disease Control and Prevention. Chronic Kidney Disease in the United States, 2023. Accessed February 17, 2024. https://www.cdc.gov/kidneydisease/pdf/CKD-Factsheet-H.pdf  

 

2. Mark PB, Sarafidis P, Ekart R, et al. SGLT2i for evidence-based cardiorenal protection in diabetic and non-diabetic chronic kidney disease: a comprehensive review by EURECA-m and ERBP working groups of ERA. Nephrol Dial Transplant. 2023;38(11):2444-2455.  

 

3. Wiviott SD, Raz I, Bonaca MP, et al. Dapagliflozin and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2019;380(4):347-357. 

 

4. Perkovic V, Jardine MJ, Neal B, et al. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med. 2019;380(24):2295-2306.  

 

5. Zinman B, Wanner C, Lachin LM, et al. Empagliflozin, cardiovascular outcomes and mortality in type 2 diabetes. N Engl J Med. 2015;373(22):2117-2128. 

 

6. Heerspink HJL, Stefansson BV, Correa-Rotter R, et al. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383(15):1436-1446. 

 

7. The EMPA-KIDNEY Collaborative Group; Herrington WG, Staplin N, Wanner C, et al. Empagliflozin in patients with chronic kidney disease. N Engl J Med. 2022;388(2):117-127. 

 

8. The EMPA-KIDNEY Collaborative Group; Herrington WG, Wanner C, Green JB, et al. Design, recruitment and baseline characteristics of the EMPA-KIDNEY trial. Nephrol Dial Transplant. 2022;37:1317-1329.  

 

9. Wheeler DC, Stefansson BV, Batiushin O, et al. The Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) trial: baseline characteristics. Nephrol Dial Transplant. 2020;35:1700-1711.  

 

10. Scheen AJ. Real-life underuse of SGLT2 inhibitors for patients with type 2 diabetes at high cardiorenal risk. Diabetes Epidemiol Manag. 2024;13:100184 https://doi.org/10.1016/j.deman.2023.100184. 

 

11. Lamprea-Montealegre JA, Madden E, Tummalapalli SL, et al. Prescription patterns of cardiovascular- and kidney-protective therapies among patients with type 2 diabetes and chronic kidney disease. Diabetes Care. 2022;45(12):2900-2906. 

 

12. Singh T, Li T, Mandelbrot D, et al. Prescribing patterns for sodium-glucose cotransporter 2 inhibitors: a survey of nephrologists. Kidney Int Rep. 2023;8(8):1669-1671. 

 

13. Nee R, Yuan CM, Narva AS, et al. Overcoming barriers to implementing new guideline-directed therapies for chronic kidney disease. Nephrol Dial Transplant. 2023;38(3):532-541.