Cardiologist collaboration required for patients to get cardiorenal benefit of SGLT2i


By Mardi Chapman

29 Sep 2020

Evidence supporting the multiple clinical benefits of SGLT2 inhibitors and GLP-1 receptor agonists has outpaced their effective implementation in clinical practice, according to the American Heart Association.

An AHA scientific statement, Cardiorenal Protection With the Newer Antidiabetic Agents in Patients With Diabetes and Chronic Kidney Disease, said the antihyperglycaemic agents are typically only initiated by GPs or endocrinologists for their patients with diabetes.

Yet the evidence is clear that they also have a role beyond diabetes.

“Given the well-proven CVD and CKD benefits from these drug classes in RCTs, there is an urgent need to incorporate multidisciplinary care in the identification of high-risk patients who may benefit from these agents.”

The AHA called for multidisciplinary efforts from primary care physicians, cardiologists, nephrologists, endocrinologists, pharmacists, advanced practitioners, and other allied health professionals toward providing targeted therapies for CVD and CKD risk reduction in patients with T2D.

As an example of the growing evidence for the agents, the DAPA-CKD trial has recently reported that dapagliflozin significantly reduces the risk of a composite of a sustained decline in the estimated GFR of at least 50%, end-stage kidney disease, or death from renal or cardiovascular causes in patients with chronic kidney disease, regardless of the presence or absence of diabetes.

The RCT, published in the NEJM, comprised more than 4,000 patients from 386 sites across 21 countries randomised to either dapagliflozin (10 mg once daily) or placebo.

The primary composite outcome occurred in 9.2% of the dapagliflozin group compared to 14.5% in the control group (HR 0.61; p<0.001). The event rates for all individual components of the composite outcome also favoured dapagliflozin.

The number of participants who needed to be treated during the trial period to prevent one primary outcome event was 19 (95% CI, 15 to 27).

“Our trial confirms that the kidney protective effects of SGLT2 inhibitors extend to the broader population of persons with chronic kidney disease without type 2 diabetes, for whom ACE inhibitors are the only pharmacologic treatments that have been shown to prevent kidney failure,” the study said.

Commenting on the DAPA-CKD study, Associate Professor Meg Jardine from The George Institute for Global Health, said dapagliflozin’s benefits were shown to include a 44% reduction in the progression of kidney disease, a 29% reduction in hospital admissions for heart failure or deaths from a cardiovascular cause, and a 31% reduction in deaths from any cause.

Associate Professor Jardine, a nephrologist, was a co-investigator on the 2019 CREDENCE trial which found that canagliflozin reduced the progression of kidney disease, reduced cardiovascular events and reduced heart failure events in people with diabetic kidney disease.

“A key feature of the DAPA-CKD trial was that it involved people with and without diabetes, and the benefits appear to apply equally to both groups. The DAPA-CKD trial now shows those benefits extend to people with kidney disease who don’t have diabetes,” she said.

“These results herald an exciting new therapeutic option for people with chronic kidney disease.”

The AHA said multispecialty care models were required to help integrate these evidence based therapies into clinical care. Practical issues to encourage their safe and effective use included:

  • Identification of at-risk patients
  • Selection of appropriate therapy
  • Adjustment of concomitant therapies and deprescribing
  • Patient counseling
  • Longitudinal clinical follow-up.

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