From the Guidelines
SGLT2 inhibitors are not recommended for this 90-year-old woman with a GFR of 15 ml/min, diabetes, hypertension, and proteinuria. According to the most recent and highest quality study 1, SGLT2 inhibitors are recommended for patients with type 2 diabetes, chronic kidney disease, and an eGFR ≥20 ml/min per 1.73 m². Since this patient's eGFR is 15 ml/min, which is below the recommended threshold, SGLT2 inhibitors are not suitable.
Key Considerations
- The patient's severe kidney impairment, with a GFR of 15 ml/min, increases the risk of adverse effects such as volume depletion, hypotension, electrolyte abnormalities, and acute kidney injury 1.
- The benefits of SGLT2 inhibitors, including kidney and cardiovascular protection, are not likely to outweigh the risks in this patient due to her advanced kidney disease.
- Alternative diabetes management options, such as insulin, certain GLP-1 receptor agonists (like dulaglutide), or dipeptidyl peptidase-4 inhibitors (like linagliptin), may be safer and more effective for this patient.
Management Recommendations
- The patient should be managed by a multidisciplinary team, including nephrology, to address her advanced kidney disease and diabetes.
- Alternative diabetes management options should be considered, taking into account the patient's kidney function, age, and other comorbidities.
- Close monitoring of the patient's kidney function, blood pressure, and electrolyte levels is crucial to prevent potential complications.
From the FDA Drug Label
To reduce the risk of end-stage kidney disease, doubling of serum creatinine, cardiovascular death, and hospitalization for heart failure in adults with type 2 diabetes mellitus and diabetic nephropathy with albuminuria ( 1). Not recommended for use to improve glycemic control in patients with type 2 diabetes mellitus with an eGFR less than 30 mL/min/1.73 m 2( 1).
The patient has an eGFR of 15, which is less than 30 mL/min/1.73 m^2. SGLT2 inhibitors, such as canagliflozin, are not recommended for use to improve glycemic control in patients with type 2 diabetes mellitus and an eGFR less than 30 mL/min/1.73 m^2 2.
- The patient's impaired renal function (GFR 15) is a contraindication for the use of SGLT2 inhibitors to improve glycemic control.
- The patient's diabetes mellitus, hypertension, and proteinuria are relevant conditions, but the primary concern is the patient's impaired renal function.
From the Research
Patient Profile
- Age: 90 years old
- Impaired renal function: GFR 15
- Diabetes Mellitus (DM)
- Hypertension (HTN)
- Proteinuria: 0.25g/24 hours
SGLT2 Inhibitors and Renal Function
- The pharmacodynamic response to SGLT-2 inhibitors declines with increasing severity of renal impairment, requiring dosage adjustments or restrictions with moderate-to-severe renal dysfunction 3
- The glucose-lowering efficacy of SGLT2 inhibitors is dependent on renal function, but the cardiovascular and renal benefits appear to be maintained to estimated glomerular filtration levels as low as 30 mL/min/1.73 m2 4
- SGLT2 inhibitors can reduce the risk of development or worsening of albuminuria, a marker of renal damage, through various mechanisms 4
- Introduction of an SGLT2 inhibitor in patients with a very low GFR is not encouraged due to an initial dip in GFR 5
Safety Concerns
- Hospitalized patients treated with SGLT2 inhibitors are at increased risk of diabetic ketoacidosis, euglycemic diabetic ketoacidosis, hypovolemia, and urinary tract infections 6
- SGLT2 inhibitors should be avoided for the inpatient management of hyperglycemia due to significant safety concerns 6
Treatment Considerations
- The benefits and risks of SGLT2 inhibitors should be carefully considered in patients with impaired renal function, particularly those with a GFR as low as 15 3, 4, 5
- The potential renoprotective effects of SGLT2 inhibitors may be beneficial for patients with proteinuria and impaired renal function, but the evidence is not directly applicable to patients with a GFR of 15 4, 5