Most Eligible Patients With Diabetic Kidney Disease Not Receiving SGLT2 Inhibitor Prescriptions

Two-thirds of patients with diabetic kidney disease meeting the criteria for treatment with sodium-glucose cotransporter 2 (SGLT2) inhibitors are not being prescribed them, running counter to guidance from the American Diabetes Association (ADA), according to a new study.

Clinicians are focusing treatment on younger patients with poor glycemic control when the guidelines state that treatment should be geared toward with those with a high estimated glomerular filtration rate (eGFR) even when glycated hemoglobin (A1C) levels are controlled, researchers from Korea wrote in a study published in BMC Nephrology. Also, clinicians should not shy away from treating the elderly with SGLT2 inhibitors when treatment could be beneficial.

Diabetic kidney disease (DKD), or chronic kidney disease (CKD) attributed to diabetes, is diagnosed based on eGFR and the presence of albumin in the urine. It occurs in 20% to 40% of patients with diabetes and is caused by hyperglycemia, hypertension, aging, and other risk factors for CKD. The ADA recommends SGLT2 inhibitors for patients with type 2 diabetes (T2D) and DKD with an eGFR of at least 30 mL/min/1.73 m² and urinary albumin-to-creatinine ratio (UACR) greater than 30 mg/g, particularly in those whose ratio is greater than 300 mg/g.

However, with evidence indicating that SGLT2 inhibitors are underutilized for eligible patients and that primary doctors are deferring the decision to endocrinologists, researchers investigated the actual percentages and the barriers to greater use.

The study found that of those in the high-risk group (eGFR of at least 45 mL/min/1.73 m² and UACR of at least 30 mg/g), only 32.9% of patients were receiving the drug treatment, with those aged 65 years and older and with recent hospitalizations tending to have lower numbers. The prevalence of high-risk patients with CKD eligible for the drug was higher among those 65 years and older (28.6%) than among those who were younger than 65 years (21.8%). Only 17.6% of elderly patients, however, received SGLT2 inhibitors compared with 45.8% of those under 65, despite trials finding that older patients have similar or greater benefits than young patients.

Conversely, A1C level, body mass index, presence of diabetic retinopathy, and previous heart failure were correlated with greater use despite not being part of the ADA guidelines.

Differences in A1C levels at SGLT2 inhibitor initiation were “due to clinical inertia of physicians not to change medications when glycemic control is in the target range” despite the presence of cardiovascular disease or CKD, the authors said. In fact, the presence of cardiovascular disease or CKD increased the odds of patients starting on SGLT2 inhibitors, the authors said.

The authors called on health plans to support evidence-based treatment strategies regarding SGLT2 inhibitors to improve renal outcomes of patients with DKD. They also called for efforts at more accurate diagnosis of CKD to identify eligible patients, having regulatory authorities extend the eGFR values above 30 mL/min/1.73 m², and individualizing treatment of T2D based on CKD status.

The study entailed 3703 study subjects from 4 teaching hospitals from the Seoul area from September 2019 to May 2020. Among all study subjects, 25.8% were treated with an SGLT2 inhibitor, with an average age of 61.4 years. The percentage of those treated with SGLT2 inhibitors for those in the group just over the thresholds for eGFR and UACR was only 7%.

Reference

Jeong SJ, Lee SE, Shin DH, et al. Barriers to initiating SGLT2 inhibitors in diabetic kidney disease: a real-world study. BMC Nephrol. 2021;22:177. doi:10.1186/s12882-021-02381-3