Author(s)
Stefanie C. Nigro, PharmD, BCACP, CDE
Jennifer N. Clements, PharmD, BCPS, BCACP, BC-ADM, CDCES
Reviewers:
Sean Lasota, PharmD, BCACP
W. Cheng Yuet, PharmD, BCACP, CDCES
Citation: Heerspink HJL, Stefánsson BV, Correa-Rotter R, et al. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020; 383: 1436-1446.
The Problem
Yawn. Are you bored reading, hearing, and talking about sodium glucose co-transporter 2 inhibitors (SGLT2i)? Sure, we all know they improve glycemic control. Yes, they can improve cardiovascular outcomes in people with diabetes. And, yes, they reduce the risk of heart failure exacerbations in people with or without diabetes. But what if these drugs changed the way we treat chronic kidney disease (CKD)? Would that pique your interest? Until now, only two classes of medications have been definitively shown to delay the decline in renal function in patients with CKD: angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs).1-4 And despite the efficacy of these drugs, cases of CKD continue to rise, life expectancy continues to decline, and medical costs continue to soar. In 2017, Medicare spent $84 billion treating patients with CKD and an additional $34 billion for patients on dialysis.5 Can SGLT2i change the course of the disease and reduce mortality? Let’s take a look, shall we?
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I think that the newer evidence for the SGLT2’s is fascinating, but one of the biggest barriers that I continue to see in my practice is the cost. Most of the patients that may benefit are either Medicare age, or approaching Medicare age, and on other costly medications (DOACs, inhalers, the list goes on). So, if we were to start a 63-64 year old on an SGLT2 for CKD benefit, there is the possibility that they won’t be able to afford it just about when the CKD benefit is about to manifest.
Dawn, I agree that this is a major concern among both patients and prescribers. I am hoping that cost-effectiveness data will help insurers re-evaluate their tiering structure for these critically important drugs. Now that we are seeing the SGLT2i extend beyond “a diabetes only drug”, it’s important for payers to help with the accessibility and affordability.
The VA recognized this 2 or 3 years ago, making empagliflozin formulary and available to diabetic patients with CVD and CKD. in the past year, it has become the preferred 2nd line agent for all DM patients behind metformin and has been unrestricted to non-diabetic patients with HFrEF or CKD who are already on standard therapy. They are even tracking increased utilization in HFrEF as a positive performance metric.