SGLT2 Inhibitors: Clinical Pearls for Primary Care

Dr Kevin Fernando provides an overview of SGLT2 inhibitor use for primary care.
https://www.medscape.com/viewarticle/1001495?src=soc_yt

-- TRANSCRIPT --
In this podcast, I'm going to give an update on SGLT2 inhibitors, which I reckon are the biggest therapeutic advance in my career to date. I've been prescribing SGLT2 inhibitors for over 10 years now in primary care, and during that time, prescribing indications of SGLT2 inhibitors have significantly expanded beyond their original use for glycemic management in type 2 diabetes, driven by a rapidly evolving and high-quality evidence base.

SGLT2 inhibitors are now indicated for atherosclerotic cardiovascular disease risk reduction for those with type 2 diabetes, all subtypes of heart failure — heart failure with reduced ejection fraction and heart failure with preserved ejection fraction — as well as chronic kidney disease in people with, and indeed, without type 2 diabetes.

In my opinion, SGLT2 inhibitors are now the new standard of care for cardiovascular, renal, and metabolic protection in people living with type 2 diabetes, and we should consider them as primary and secondary prevention agents, independent of their glucose-lowering benefits. Similar to how we all, in primary care, consider a statin for anyone living with type 2 diabetes at increased cardiorenal risk, we should also consider starting an SGLT2 inhibitor for all with type 2 diabetes at increased cardiorenal risk.

Multiple recently updated guidelines across the world have reflected this shift from a glucocentric approach to the management of type 2 diabetes to thinking beyond glycemia and identifying significant comorbidities alongside type 2 diabetes, such as atherosclerotic cardiovascular disease, all subtypes of heart failure, and chronic kidney disease, and using these comorbidities to guide choice of therapy independent of glucose control.

Now, of course, I'm not suggesting that good glucose control is no longer important. Good glucose control protects against the microvascular complications of diabetes, but good glucose control has only a modest impact on the macrovascular complications of diabetes, which often have a bigger impact on quality and quantity of life.

Recently updated United Kingdom NICE guidelines for type 2 diabetes remind us to assess HbA1c, cardiovascular risk, and kidney function in all people living with type 2 diabetes. For those with a background of all subtypes of heart failure or established atherosclerotic cardiovascular disease, it is recommended to offer metformin, and as soon as that metformin is well tolerated, we should offer an SGLT2 inhibitor with proven cardiovascular benefit, independent of glucose control — that is to say, even if that individual's HbA1c is within their target range.

Moreover, if that person living with type 2 diabetes has a 10-year cardiovascular risk of greater than or equal to 10%, we should do the same: Start metformin, and as soon as that metformin is well tolerated, add in an SGLT2 inhibitor with proven cardiovascular benefit, independent of glucose control.

Furthermore, recently updated United Kingdom Kidney Association guidelines for SGLT2 inhibitor use in adults with kidney disease give Grade 1a recommendations for SGLT2 inhibitor initiation in people living with type 2 diabetes with an eGFR of 20-45 mL/min or an eGFR over 45 mL/min with a urinary ACR greater than or equal to 25 mg/mmol. Again, we should be initiating the SGLT2 inhibitor in this context independent of glucose control, even if HbA1c is within target range.

Transcript in its entirety can be found by clicking here:
https://www.medscape.com/viewarticle/1001495?src=soc_yt