Guideline Summary: Sodium-Glucose Cotransporter-2 (SGLT-2) Inhibitors for Adults with Chronic Kidney Disease
4 Oct, 2024 | 11:14h | UTCIntroduction
A recent clinical practice guideline published in The BMJ titled “Sodium-glucose cotransporter-2 (SGLT-2) inhibitors for adults with chronic kidney disease” provides evidence-based recommendations on the use of SGLT-2 inhibitors in adults with chronic kidney disease (CKD), regardless of diabetes status. The guideline aims to assist clinicians in making informed decisions to improve patient outcomes in CKD management.
Key Recommendations and Patient Care Implications
- Risk Stratification
- Assessment: Patients with CKD should be stratified based on their risk of disease progression and complications using estimated glomerular filtration rate (eGFR) and albuminuria levels, following the Kidney Disease Improving Global Outcomes (KDIGO) classification.
- Clinical Implication: Proper risk stratification guides the intensity of treatment and monitoring.
- Use of SGLT-2 Inhibitors
- Low to Moderate Risk Patients: For adults at low or moderate risk, the guideline suggests administering SGLT-2 inhibitors (weak recommendation in favor).
- Patient Care Impact: Clinicians should discuss potential benefits and risks with patients, considering individual preferences.
- High to Very High Risk Patients: For adults at high or very high risk, a strong recommendation is made to administer SGLT-2 inhibitors.
- Patient Care Impact: Clinicians should prioritize initiating SGLT-2 inhibitors in these patients to reduce risks of mortality and progression to kidney failure.
- Low to Moderate Risk Patients: For adults at low or moderate risk, the guideline suggests administering SGLT-2 inhibitors (weak recommendation in favor).
- Benefits of SGLT-2 Inhibitors
- Outcomes: Reduction in all-cause mortality, cardiovascular mortality, hospitalization for heart failure, kidney failure, non-fatal myocardial infarction, and non-fatal stroke.
- Clinical Implication: SGLT-2 inhibitors provide significant protective effects on cardiovascular and kidney health in CKD patients.
- Potential Harms and Monitoring
- Adverse Effects: Minimal increase in risks of acute kidney injury requiring dialysis, bone fractures, lower limb amputations, ketoacidosis, genital infections, or symptomatic hypovolemia.
- Patient Counseling: Patients should be informed about possible side effects and advised on when to seek medical attention.
- Monitoring: Routine laboratory monitoring is not generally necessary, except in high-risk individuals.
- Practical Considerations for Prescribing
- Initiation: Start SGLT-2 inhibitors in patients with eGFR ≥20 mL/min/1.73 m².
- Continuation: Medications can be continued even if eGFR falls below 20 mL/min/1.73 m² until dialysis is initiated.
- Dosage: Initiate at the highest possible dose without the need for titration.
- Drug Selection: Canagliflozin, dapagliflozin, and empagliflozin are suitable options.
- Concurrent Medications: Review and adjust diuretics to prevent volume depletion.
- Patient Education and Self-Management
- Sick Day Rules: Advise patients to temporarily discontinue SGLT-2 inhibitors during acute illnesses causing dehydration.
- Lifestyle Modifications: Encourage adherence to medication and healthy lifestyle changes to enhance treatment efficacy.
- Applicability and Exceptions
- Applicable Populations: Recommendations apply broadly to adults with CKD, with or without type 2 diabetes.
- Exceptions: Caution or alternative approaches may be necessary for patients:
- Receiving kidney replacement therapy.
- With kidney transplants, polycystic kidney disease, rare kidney diseases.
- With eGFR <20 mL/min/1.73 m² not on replacement therapy.
Conclusion
The guideline underscores the importance of incorporating SGLT-2 inhibitors into the management plan for adults with CKD to improve survival and reduce cardiovascular and kidney-related complications. Clinicians should evaluate each patient’s risk profile and engage in shared decision-making to optimize treatment outcomes.