From the Guidelines
Initiation of SGLT2 inhibitors should occur at a Glomerular Filtration Rate (GFR) of 20 mL/min/1.73 m² or higher.
Key Considerations
- The use of SGLT2 inhibitors is recommended for adults with type 2 diabetes who have chronic kidney disease (CKD) with an estimated glomerular filtration rate (eGFR) of 20 mL/min/1.73 m² or higher 1.
- These inhibitors are used not only for glycemic management but also for slowing the progression of CKD and reducing cardiovascular events 1.
- While the glycemic benefits of SGLT2 inhibitors may be reduced at eGFR <45 mL/min per 1.73 m², their use is still recommended for renal and cardiovascular risk reduction at eGFR ≥20 mL/min/1.73 m² 1.
- In the context of hypertension management in CKD, SGLT2 inhibitors are also recommended for their modest blood pressure-lowering properties in patients with eGFR >20 mL/min/1.73 m² 1.
Clinical Application
- The decision to initiate SGLT2 inhibitors should be based on the presence of CKD (eGFR 20–60 mL/min/1.73 m² and/or albuminuria) in adults with type 2 diabetes, considering their benefits in reducing CKD progression and cardiovascular events.
- It is essential to monitor renal function and adjust the treatment plan accordingly, as the efficacy and safety of SGLT2 inhibitors can vary with declining renal function.
From the Research
Glomerular Filtration Rate (GFR) for Initiating Sodium-Glucose Cotransporter 2 (SGTL2) Inhibitors
- The initiation of SGTL2 inhibitors is not strictly limited to a specific GFR threshold, as their benefits extend to patients with various levels of kidney function 2, 3, 4.
- Studies have shown that SGTL2 inhibitors can be effective in reducing major cardiovascular events and hospitalization for heart failure, as well as slowing the progression of chronic kidney disease (CKD), even in patients with an estimated GFR (eGFR) as low as 30 ml/min/1.73 m² 2.
- However, current restrictive criteria for the prescription and reimbursement of SGTL2 inhibitors in some regions, such as Belgium, may require an eGFR superior to 60 ml/min/1.73 m² for initiation and interruption if eGFR falls below 45 ml/min/1.73 m² 2.
- Meta-analyses have demonstrated that SGTL2 inhibitors can reduce heart failure events and kidney disease progression across different eGFR subgroups, including those with eGFR < 45 to < 60, and ≥ 60 ml/min/1.73 m² 3.
- The absolute benefits of SGTL2 inhibitors on kidney and cardiac outcomes may be greater in patients with lower eGFR and higher albuminuria 3, 4.
Considerations for Initiating SGTL2 Inhibitors at Lower GFR Thresholds
- Some studies suggest that initiating SGTL2 inhibitors at lower HbA1c thresholds may attenuate eGFR decline in type 2 diabetes patients with and without cardiorenal disease 5.
- Greater renoprotection from SGTL2 inhibitors may be observed in patients with baseline eGFR < 60 ml/min/1.73 m², albuminuria, and/or treatment with renin-angiotensin-system inhibitors or insulin 5.
- The relationships between SGTL2 inhibitors and kidney function are complex, and a simple model may not fully account for the beneficial effects of these agents on the diabetic kidney 6.