What are the British guidelines for using SGLT2 (sodium-glucose cotransporter 2) inhibitors in a patient with hypertension, asthma, fatty liver disease, proteinuria, and chronic kidney disease (CKD) with impaired renal function, specifically a glomerular filtration rate (GFR) of 35 milliliters per minute?

From the Guidelines

Based on British guidelines, SGLT2 inhibitors can be considered for a patient with hypertension, asthma, fatty liver, proteinuria, and CKD with GFR 35ml/min, as they offer cardiorenal protection beyond glucose control, and the patient's comorbidities strengthen the case for their use. The most recent and highest quality study, 1, recommends the use of SGLT2 inhibitors, such as dapagliflozin, for patients with type 2 diabetes and CKD, with an eGFR ≥20 mL/min/1.73 m², to reduce CKD progression and cardiovascular events.

Key Considerations

• SGLT2 inhibitors, such as dapagliflozin 10mg once daily, are licensed in the UK for CKD with eGFR ≥25ml/min, and can be initiated for most patients with type 2 diabetes, CKD, and eGFR ≥20 ml/min/1.73 m², as stated in 1 and 1.
• The patient's comorbidities, including hypertension, asthma, fatty liver, proteinuria, and CKD, actually strengthen the case for SGLT2 inhibitor use, as these medications have shown benefits in non-alcoholic fatty liver disease, and significantly reduce proteinuria and slow CKD progression.
• Asthma is not a contraindication for SGLT2 inhibitor use.
• The patient should be monitored for side effects, including genital mycotic infections, urinary tract infections, and volume depletion, as noted in 1.
• If the patient is on diuretics, dose adjustment may be needed to prevent hypotension, and renal function should be monitored regularly, though SGLT2 inhibitors typically cause an initial, benign dip in eGFR that stabilizes over time, as stated in 1 and 1.

Monitoring and Risk Mitigation

• The patient should be counseled on genital hygiene to reduce the risk of genital mycotic infections, as noted in 1.
• The patient should be monitored for hypovolemia and hypoglycemia, and adjustment of background therapies may be needed, as stated in 1.
• The patient should be educated on the signs and symptoms of diabetic ketoacidosis, and blood or urine ketone monitoring may be used for ketosis detection, as noted in 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

British Guidelines for SGLT2 Inhibitors in Hypertension, Asthma, Fatty Liver, Proteinuria, and CKD

• The British guidelines for using SGLT2 inhibitors in patients with hypertension, asthma, fatty liver, proteinuria, and chronic kidney disease (CKD) with a glomerular filtration rate (GFR) of 35ml/min are not explicitly stated in the provided studies.
• However, according to 2, SGLT2 inhibitors have shown promise in slowing disease progression in patients with CKD, including those with and without type 2 diabetes.
• The studies provided do not specifically address the use of SGLT2 inhibitors in patients with asthma or fatty liver, but they do discuss the importance of managing hypertension and proteinuria in patients with CKD.

Management of Hypertension and Proteinuria in CKD

• 3 notes that Japanese guidelines recommend angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) as first-line therapy in hypertensive patients with CKD and proteinuria.
• 4 discusses the pathophysiological mechanisms that contribute to hypertension in CKD, including sympathetic nervous system activity, the renin-angiotensin-aldosterone system, and the role of sodium.
• 5 highlights the importance of controlling blood pressure to slow nephropathy progression in patients with CKD.
• 6 examines the effect of an angiotensin receptor blocker on patients with moderate to severe heart failure and CKD, and finds that it reduces the risk of first morbid events in patients with CKD.

Use of SGLT2 Inhibitors in CKD

• 2 summarizes the potential therapeutic approaches for managing CKD, including the use of SGLT2 inhibitors, which have shown a significant reduction in the risk of CKD progression in patients with and without type 2 diabetes.
• The studies provided suggest that SGLT2 inhibitors may be a useful treatment option for patients with CKD, but do not provide specific guidance on their use in patients with hypertension, asthma, fatty liver, proteinuria, and CKD with a GFR of 35ml/min.