Sodium-Glucose Cotransporter-2 inhibitor (SGLT2i) Prescription Rates Amongst Diabetologists for Type 2 Diabetes Patients with Albuminuric Diabetic Kidney Disease:
A Real-World Study at a Diabetes Center in Bangkok
DOI:
https://doi.org/10.15605/jafes.040.02.22Keywords:
sodium-glucose cotransporter 2 inhibitors (SGLT2i), prescription rates, diabetic kidney disease, real-world data, ThaiAbstract
Background. Despite the beneficial effects of SGLT2i in reducing kidney disease progression and mortality in people with diabetic kidney disease (DKD), the use of SGLT2i in this population remains low.
Objective. To explore the prescription rates of SGLT2i in type 2 diabetes (T2D) patients with albuminuric DKD and to assess
clinician-perceived barriers to prescribing SGLT2i.
Methodology. A retrospective study of all medical records of T2D patients with albuminuric DKD and eGFR ≥20 ml/
min/1.73 m2 in 2023 who had been treated by 13 diabetologists was conducted at Vimut-Theptarin Hospital, a private tertiary diabetes center in Bangkok. In cases of no documentation of non-prescribed SGLT2i, treating physicians were contacted to explore the reasons.
Result. A total of 282 medical records were reviewed (mean age 65.9 ± 10.0 years, A1C 7.5 ± 1.2 %, duration of diabetes 19.7 ± 10.4 years, mean eGFR 68.3 ± 24.1 mL/min/1.73 m2, median UACR 151 (IQR 309) mg/g Cr, RAS inhibitors usage 80.1%). The SGLT2i prescription rate was 58.9% in 2023. Coronary artery disease, age ≥65 years, eGFR <60 mL/min/1.73 m2, optimal A1C and LDL control, use of thiazolidinedione were associated with SGLT2i prescription. Clinical inertia (31.9 %) was the most common reason for not prescribing SGLT2i in eligible patients, followed by cost concerns (18.1%) and frailty of patients (15.5%).
Conclusion. Prescribing SGLT2i to T2D patients with albuminuric DKD remains suboptimal among diabetologists due to clinical inertia, medication costs, and frailty. Our study underscores actions aimed at improving SGLT2i prescription
rates in routine practice.
Downloads
References
1. Kalyani RR. Glucose-lowering drugs to reduce cardiovascular risk in type 2 diabetes. N Engl J Med. 2021;384(13):1248-60. https://pubmed.ncbi.nlm.nih.gov/33789013. https://doi.org/10.1056/NEJMcp2000280
2. Zinman B, Wanner C, Lachin JM, et al. EMPA-REG OUTCOME investigators. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015;373(22):2117-28. https://pubmed.ncbi.nlm.nih.gov/26378978 https://doi.org/10.1056/NEJMoa1504720
3. Wanner C, Inzucchi SE, Lachin JM, et al. EMPA-REG OUTCOME investigators. Empagliflozin and progression of kidney disease in type 2 diabetes. N Engl J Med. 2016;375(4):323-34. https://pubmed.ncbi.nlm.nih.gov/27299675 https://doi.org/10.1056/NEJMoa1515920
4. Neal B, Perkovic V, Mahaffey KW, et al. CANVAS program collaborative group. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med. 2017;377(7):644-57. https://pubmed.ncbi.nlm.nih.gov/28605608 https://doi.org/10.1056/NEJMoa1611925
5. Wiviott SD, Raz I, Bonaca MP, et al. DECLARE–TIMI 58 investigators. Dapagliflozin and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2019;380(4):347-57. https://pubmed.ncbi.nlm.nih.gov/30415602 https://doi.org/10.1056/NEJMoa1812389
6. Zelniker TA, Wiviott SD, Raz I, et al. SGLT2 inhibitors for primary and secondary prevention of cardiovascular and renal outcomes in type 2 diabetes: a systematic review and meta-analysis of cardiovascular outcome trials. Lancet. 2019;393(10166):31–9. https://pubmed.ncbi.nlm.nih.gov/30424892 https://doi.org/10.1016/S0140-6736(18)32590-X
7. Perkovic V, de Zeeuw D, Mahaffey KW, et al. Canagliflozin and renal outcomes in type 2 diabetes: results from the CANVAS Program randomised clinical trials. Lancet Diabetes Endocrinol. 2018;6(9):691–704. https://pubmed.ncbi.nlm.nih.gov/29937267 https://doi.org/10.1016/S2213-8587(18)30141-4
8. Perkovic V, Jardine MJ, Neal B, et al. CREDENCE trial investigators. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med. 2019;380(24): 2295–306. https://pubmed.ncbi.nlm.nih.gov/30990260 https://doi.org/10.1056/NEJMoa1811744
9. Heerspink HJL, Stefansson BV, Correa-Rotter R, et al. DAPA-CKD trial committees and investigators. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383(15):1436-46. https://pubmed.ncbi.nlm.nih.gov/32970396 https://doi.org/10.1056/NEJMoa2024816
10. Rossing P, Caramori ML, Chan JCN, et al. Executive summary of the KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease: An update based on rapidly emerging new evidence. Kidney Int. 2022;102(5):990-9. https://pubmed.ncbi.nlm.nih.gov/36272755 https://doi.org/10.1016/j.kint.2022.06.013
11. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2024;105(4S):S117-314. https://pubmed.ncbi.nlm.nih.gov/38490803 https://doi.org/10.1016/j.kint.2023.10.018.
12. Alonso A, Morris AA, Naimi AI, et al. Use of sodium-glucose cotransporter-2 inhibitors and angiotensin receptor-neprilysin inhibitors in patients with atrial fibrillation and heart failure from 2021 to 2022: An analysis of real-world data. J Am Heart Assoc. 2024;13(6): e032783. https://pubmed.ncbi.nlm.nih.gov/38456406 https://pmc.ncbi.nlm.nih.gov/articles/PMC11010035 https://doi.org/10.1161/JAHA.123.032783
13. Pradhan AM, Lussier M, Nguyen M, et al. Qualitative evaluation to understand barriers and facilitators to prescribing angiotensin receptor-neprilysin inhibitors (ARNi) and sodium-glucose cotransporter inhibitors (SGLT2i) in patients with heart failure with reduced ejection fraction (HFrEF). J Am Pharm Assoc (2003). 2024:102224. https://pubmed.ncbi.nlm.nih.gov/39209218 https://doi.org/10.1016/j.japh.2024.102224
14. Warden BA, Purnell JQ, Duell PB, et al. Real-world utilization of pharmacotherapy with new evidence-based cardiovascular indications in an academic preventive cardiology practice. Am J Prev Cardiol. 2021;5:100144. https://pubmed.ncbi.nlm.nih.gov/34327487 https://pmc.ncbi.nlm.nih.gov/articles/PMC8315383 https://doi.org/10.1016/j.ajpc.2020.100144
15. Dharia A, Khan A, Sridhar VS, et al. SGLT2 inhibitors: The sweet success for kidneys. Annu Rev Med. 2023;74: 369-84. https://pubmed.ncbi.nlm.nih.gov/36706745. https://doi.org/10.1146/annurev-med-042921-102135.
16. Wang C, Zhou Y, Kong Z, et al. The renoprotective effects of sodium-glucose cotransporter 2 inhibitors versus placebo in patients with type 2 diabetes with or without prevalent kidney disease: A systematic review and meta-analysis. Diabetes Obes Metab. 2019;21(4):1018-26. https://pubmed.ncbi.nlm.nih.gov/30565382. https://doi.org/10.1111/dom.13620.
17. Agarwal R, Fouque D. The foundation and the four pillars of treatment for cardiorenal protection in people with chronic kidney disease and type 2 diabetes. Nephrol Dial Transplant. 2023;38(2):253-7. https://pubmed.ncbi.nlm.nih.gov/36535638 https://pmc.ncbi.nlm.nih.gov/articles/PMC9923692 https://doi.org/10.1093/ndt/gfac331
18. Sriphrapradang C, Thewjitcharoen Y, Buranapin S, et al. Effectiveness and safety of sodium-glucose co-transporter-2 inhibitors in Thai adults with type 2 diabetes mellitus: a real-world study. Curr Med Res Opin. 2020;36(10):1601-10. https://pubmed.ncbi.nlm.nih.gov/32776785 https://doi.org/10.1080/03007995.2020.1808454
19. Ahuja V, Chou CH. Novel therapeutics for diabetes: Uptake, usage trends, and comparative effectiveness. Curr Diab Rep. 2016;16(6):47. https://pubmed.ncbi.nlm.nih.gov/27076180 https://doi.org/10.1007/s11892-016-0744-4.
20. McCoy RG, Dykhoff HJ, Sangaralingham L, et al. Adoption of new glucose-lowering medications in the U.S.—the case of SGLT2 inhibitors: Nationwide cohort study. Diabetes Technol Ther 2019;21(12):702–12. https://pubmed.ncbi.nlm.nih.gov/31418588 https://pmc.ncbi.nlm.nih.gov/articles/PMC7207017 https://doi.org/10.1089/dia.2019.0213
21. Dave CV, Schneeweiss S, Wexler DJ, et al. Trends in clinical characteristics and prescribing preferences for SGLT2 inhibitors and GLP-1 receptor agonists, 2013–2018. Diabetes Care 2020;43(4):921-4. https://pubmed.ncbi.nlm.nih.gov/32041899 https://pmc.ncbi.nlm.nih.gov/articles/PMC7519473 https://doi.org/10.2337/dc19-1943
22. Tang S, Shao H, Ali MK, et al. Recommended and prevalent use of glucagon-like peptide-1 receptor agonists and sodium–glucose cotransporter-2 inhibitors in a national population-based sample. Ann Intern Med. 2023;176(4):582-3. https://pubmed.ncbi.nlm.nih.gov/36848654 https://pmc.ncbi.nlm.nih.gov/articles/PMC10422868 https://doi.org/10.7326/M22-3051
23. Vaduganathan M, Sathiyakumar V, Singh A, et al. Prescriber patterns of SGLT2i after expansions of U.S. Food and Drug Administration labeling. J Am Coll Cardiol. 2018;72(25):3370–2. https://pubmed.ncbi.nlm.nih.gov/30409566 https://doi.org/10.1016/j.jacc.2018.08.2202
24. Harris ST, Patorno E, Zhuo Ma, Kim SC, Paik JM. Prescribing trends of antidiabetes medications in patients with type 2 diabetes and diabetic kidney disease, a cohort study. Diabetes Care. 2021;44(10):2293–301. https://pubmed.ncbi.nlm.nih.gov/3434471 https://pmc.ncbi.nlm.nih.gov/articles/PMC8929186 https://doi.org/10.2337/dc21-0529.
25. Weissman YL, Calvarysky B, Shochat T, et al. Disparities in sodium-glucose cotransporter 2 (SGLT2) inhibitor prescription and dispensing in the Israeli population-a retrospective cohort study. Diabetes Care. 2024;47(4):692-7. https://pubmed.ncbi.nlm.nih.gov/38377492 https://doi.org/10.2337/dc23-1652.
26. Gao Y, Peterson E, Pagidipati N. Barriers to prescribing glucose-lowering therapies with cardiometabolic benefits. Am Heart J. 2020;224:47–53. https://pubmed.ncbi.nlm.nih.gov/32304879 https://doi.org/10.1016/j.ahj.2020.03.017.
27. Ng NM, Ng YS, Chu TK, Lau P. Factors affecting prescription of sodium-glucose co-transporter 2 inhibitors in patients with type 2 diabetes mellitus with established cardiovascular disease/ chronic kidney disease in Hong Kong: A qualitative study. BMC Prim Care. 2022;23(1):317. https://pubmed.ncbi.nlm.nih.gov/36476327 https://pmc.ncbi.nlm.nih.gov/articles/PMC9730654 https://doi.org/10.1186/s12875-022-01928-z.
28. Green JB, Crowley MJ, Thirunavukkarasu S, et al. The final frontier in diabetes care: Implementing research in real-world practice. Diabetes Care. 2024;47(8):1299-310. https://pubmed.ncbi.nlm.nih.gov/38907682 https://doi.org/10.2337/dci24-0001.
29. Chan JCN, Lim LL, Wareham NJ, et al. The Lancet Commission on diabetes: Using data to transform diabetes care and patient lives. Lancet. 2021;396(10267):2019-82. https://pubmed.ncbi.nlm.nih.gov/33189186 https://doi.org/10.1016/S0140-6736(20)32374-6
30. Chan JCN, Thewjitcharoen Y, Nguyen TK, et al. Effect of a web-based management guide on risk factors in patients with type 2 diabetes and diabetic kidney disease: A JADE randomized clinical trial. JAMA Netw Open. 2022;5(3):e223862. https://pubmed.ncbi.nlm.nih.gov/35333363 https://pmc.ncbi.nlm.nih.gov/articles/PMC8956973 https://doi.org/10.1001/jamanetworkopen.2022.3862
31. Segar MW, Patel KV, Keshvani N, et al. Electronic health record alert with heart failure risk and sodium glucose cotransporter 2 inhibitor prescriptions in diabetes: A randomized clinical trial. J Diabetes Sci Technol. 2024:19322968241264747. https://pubmed.ncbi.nlm.nih.gov/39254082 https://doi.org/10.1177/19322968241264747
32. Ndumele CE, Rangaswami J, Chow SL, et al. Cardiovascular-kidney-metabolic health: A presidential advisory from the American Heart Association. Circulation. 2023;148(20):1606-35. https://pubmed.ncbi.nlm.nih.gov/37807924 https://doi.org/10.1161/CIR.0000000000001184
33. Rodriguez K, Ryan D, Dickinson JK, et al. Improving quality outcomes: the value of diabetes care and education specialists. Clin Diabetes. 2022;40(3):356-65. PMID: 35979327 https://pmc.ncbi.nlm.nih.gov/articles/PMC9331628 https://doi.org/10.2337/cd21-0089.
34. Rigato M, Fadini GP, Avogaro A. Safety of sodium-glucose cotransporter 2 inhibitors in elderly patients with type 2 diabetes: A meta-analysis of randomized controlled trials. Diabetes Obes Metab 2023;25(10):2963–9. https://pubmed.ncbi.nlm.nih.gov/37402697 https://doi.org/10.1111/dom.15193.
35. Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001;135(9): 825-34. https://pubmed.ncbi.nlm.nih.gov/11694107 https://doi.org/10.7326/0003-4819-135-9-200111060-00012.
36. Mackey K, Parchman ML, Leykum LK, Lanham HJ, Noël PHm Zeber JE. Impact of the chronic care model on medication adherence when patients perceive cost as a barrier. Prim Care Diabetes 2012;6(2): 137–42. https://pubmed.ncbi.nlm.nih.gov/22264426 https://pmc.ncbi.nlm.nih.gov/articles/PMC3558316. https://doi.org/10.1016/j.pcd.2011.12.004.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Peachaphol Chongvoranond, Yotsapon Thewjitcharoen, Waralee Chatchomchuan, Ekgaluck Wanothayaroj, Siriwan Butadej, Soontaree Nakasatien, Sirinate Krittiyawong, Thep Himathongkam
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The full license text is available at: http://creativecommons.org/licenses/by-nc/3.0/legalcode.
To request permission to translate, reproduce, download, or use articles or images for commercial reuse or business purposes from the Journal of the ASEAN Federation of Endocrine Societies (JAFES), kindly complete the Permission Request for Use of Copyrighted Material Form and email jafes@asia.com or jafes.editor@gmail.com.
A written agreement will be issued to the requester once permission has been granted.
