From the Guidelines
SGLT2 inhibitors can be used in chronic kidney disease (CKD) and are now recommended for many patients with CKD, even those without diabetes, with an eGFR as low as 20 mL/min/1.73m². Medications like empagliflozin (Jardiance), dapagliflozin (Farxiga), and canagliflozin (Invokana) have shown significant benefits in slowing CKD progression and reducing cardiovascular events, as reported in recent studies 1. The typical starting dose is 10mg daily for dapagliflozin, 10mg daily for empagliflozin, or 100mg daily for canagliflozin. These medications can be initiated in patients with CKD and continued until dialysis or transplantation if tolerated.
Some key points to consider when using SGLT2 inhibitors in CKD patients include:
- Monitoring for side effects such as genital mycotic infections, urinary tract infections, volume depletion, and diabetic ketoacidosis (in diabetic patients) 1
- SGLT2 inhibitors work by blocking glucose reabsorption in the proximal tubule, which reduces hyperfiltration, decreases intraglomerular pressure, and provides renoprotective effects through multiple mechanisms including reduced inflammation and oxidative stress 1
- They also provide cardiovascular benefits independent of their glucose-lowering effects, as seen in trials such as EMPEROR-Reduced and DAPA-CKD 1
It's essential to follow up with patients to assess glycemia, volume status, and experience of other adverse effects, with consideration of the need for the addition of glucose-lowering therapy if blood glucose levels remain elevated 1. Overall, SGLT2 inhibitors are a valuable treatment option for patients with CKD, and their use should be considered in accordance with the latest clinical guidelines and evidence 1.
From the FDA Drug Label
To reduce the risk of sustained eGFR decline, end stage kidney disease, cardiovascular death, and hospitalization for heart failure in adults with chronic kidney disease at risk of progression (1) Not recommended for use to improve glycemic control in patients with type 2 diabetes mellitus with an eGFR less than 45 mL/min/1. 73 m2. Key Points:
- SGLT2 inhibitors, such as dapagliflozin, are indicated to reduce the risk of progression in adults with chronic kidney disease (CKD) at risk of progression 2.
- However, they are not recommended for use to improve glycemic control in patients with type 2 diabetes mellitus and an eGFR less than 45 mL/min/1.73 m2 2. Answer: SGLT2 inhibitors can be used in CKD, but with certain limitations and precautions, particularly in patients with advanced CKD (eGFR less than 45 mL/min/1.73 m2) 2.
From the Research
Use of SGLT2 Inhibitors in CKD
- SGLT2 inhibitors have been shown to be effective in slowing the progression of chronic kidney disease (CKD) and reducing the risk of cardiovascular events in patients with and without type 2 diabetes 3, 4, 5, 6, 7.
- These inhibitors have been found to exert renal protection by suppressing inflammation and fibrosis, and their use has been associated with improved renal function and albuminuria 3, 4, 5.
- The safety profile of SGLT2 inhibitors in patients with CKD is generally good, with similar adverse events to those seen in patients with normal renal function 5, 6.
- Several studies have demonstrated the effectiveness of SGLT2 inhibitors in patients with CKD, including those with and without type 2 diabetes, and with varying levels of kidney function 3, 4, 5, 6, 7.
Benefits of SGLT2 Inhibitors in CKD
- Reduced risk of CKD progression 3, 4, 5, 6, 7.
- Improved renal function and albuminuria 3, 4, 5.
- Reduced risk of cardiovascular events, including heart failure and death 3, 4, 5, 6, 7.
- Potential benefits in patients with CKD regardless of diabetes status, primary kidney disease, or kidney function 7.
Clinical Use of SGLT2 Inhibitors in CKD
- Dapagliflozin and canagliflozin are SGLT2 inhibitors with indications for CKD, with dapagliflozin also indicated for CKD in patients without type 2 diabetes 6.
- Clinically relevant adverse events associated with SGLT2 inhibitors include volume depletion, diabetic ketoacidosis, and genital mycotic infections 6.
- Early diagnosis and treatment of CKD are important for reducing disease progression and improving outcomes, and SGLT2 inhibitors may be a useful addition to treatment regimens 7.