In an interview with Pharmacy Times, Chiadi Ndumele, MD, PhD, MHS, chair of the American Heart Association (AHA)/American College of Cardiology (ACC) cardio-kidney-metabolic (CKM) syndrome guideline writing committee and the director of Obesity and Cardiometabolic Research at Johns Hopkins University, outlined the medication- and care-coordination-related takeaways pharmacists should know from the new CKM syndrome guideline. Ndumele highlighted the guideline's formal endorsement of glucagon-like peptide-1-based (GLP-1) therapies for their glycemic, kidney, and cardiovascular benefits, alongside kidney-protective agents—including sodium-glucose cotransporter 2 inhibitors (SGLT2is), renin-angiotensin system inhibitors, and nonsteroidal mineralocorticoid receptor antagonists (MRAs)—guided by estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (uACR).1
He emphasized that pharmacists should watch for insulin adjustments when patients start GLP-1 therapy and monitor follow-up labs at 3 to 6 months. Ndumele also discussed the guideline's call for a dedicated CKM care coordinator, describing both value-based and volume-based interdisciplinary models in which pharmacists play a central role through comprehensive medication management, patient education, and care coordination. He closed by underscoring the guideline's broader goal of shifting from siloed care to team-based, whole-person care for patients with CKM syndrome.
Pharmacy Times: Can you please introduce yourself?
Chiadi Ndumele, MD, PhD, MHS: My name is Chiadi Ndumele. I am an associate professor of medicine and epidemiology at Johns Hopkins in the Division of Cardiology, and I'm also the director of obesity and cardiometabolic research.
Pharmacy Times: The guideline formally endorses GLP-1-based therapies for the first time in this context and also emphasizes kidney-protective agents guided by both eGFR and urine albumin-to-creatinine ratio. For pharmacists who are managing these patients day to day, what are the most important medication-related takeaways from this document?
Key Takeaways
- The guideline formally endorses GLP-1-based therapies and prioritizes kidney-protective agents (SGLT2 inhibitors, RAS inhibitors, and nonsteroidal MRAs) guided by eGFR and urine albumin-to-creatinine ratio.
- Pharmacists should watch for insulin dose adjustments when patients start GLP-1 therapy and track follow-up weight/glycemic checks at 3 to 6 months, plus periodic UACR monitoring in CKD.
- The guideline calls for a dedicated CKM care coordinator—a role pharmacists are well-positioned to fill through medication management, patient education, and interdisciplinary care coordination.
Ndumele: There are really going to be some very important medication takeaways from this document for pharmacists who are directly caring for these individuals and who are supporting broader interdisciplinary teams. In this context, we do emphasize cardioprotective therapies in diabetes and obesity, so we know that GLP-1 therapies are fundamentally important as therapies that not only improve glycemic control and other metabolic risk factors, but also improve kidney outcomes in patients with diabetic kidney disease and improve cardiovascular outcomes among patients with diabetes or with certain forms of cardiovascular disease. These therapies have multisystem benefits, and there's going to be a need for further guidance for both clinicians and patients as they engage in utilizing these therapies.
Additionally, kidney-protective therapies should become a mainstay at the forefront of our clinical care, where we now have several classes of kidney-protective agents. We have SGLT2 inhibitors, in addition to traditional renin-angiotensin system inhibitors, as first-line therapies, and in patients with diabetes, chronic kidney disease (CKD), and albuminuria, we have the additional therapies of GLP-1 receptor agonists and the nonsteroidal MRA finerenone (Kerendia; Bayer). We know that these agents don't only improve kidney outcomes; they also improve cardiovascular outcomes, which are the leading cause of mortality among patients with CKD.
For all these agents, we need to make sure that we're choosing the right individuals to receive these therapies; that we're recognizing certain contraindications—for example, certain eGFR thresholds for the initiation of some kidney-protective therapies; and that we're recognizing, when we're starting individuals on GLP-1s, the need to reduce or sometimes even discontinue insulin therapy to avoid challenges with hypoglycemia. And we should also understand the monitoring parameters in terms of follow-up assessments for weight and glycemia at 3 to 6 months after starting GLP-1 therapies, for example, and follow-up assessments of uACR among individuals with CKD to not only assess residual risk but also to guide the initiation of additional kidney-protective therapies. There's no question that pharmacists have a key role here in helping to educate our clinicians, helping to educate the public, helping to support patients, and really helping to advance care for CKM syndrome.
Pharmacy Times: The guideline calls for a dedicated CKM coordination point person within care teams. What does truly coordinated, interdisciplinary CKM care look like in practice, and where do you see pharmacists fitting into that model going forward?
Ndumele: Pharmacists will really play an integral role in the CKM interdisciplinary care teams. We have several different models that are proposed within the CKM guideline for thinking about how care teams can work together. We have what we call a value-based model, where there's more remote, interdisciplinary support from clinical champions within various specialties, in addition to nurses and pharmacists, that really helps to guide and make sure that individuals at scale are receiving the appropriate therapies for CKM syndrome, particularly among patients with the confluence of diabetes, CKD, or cardiovascular conditions. We also have what we call a volume-based model, where there's really a focus on targeted referrals of high-risk patients to subspecialists, but additional support with collaboration, communication, and coordination among specialty teams and helping patients with navigation when they're seeing multiple specialists, regardless of which care model is utilized, is also important.
There's no question that we need pharmacists to play a central role with regard to processes like comprehensive medication management, with regard to providing patient support with activation and education, with regard to understanding where certain therapies are indicated or not indicated, and in general with regard to supporting collaborative care. We know from clinical trial data that interdisciplinary teams that include CKM coordination point persons have a vital impact on CKM syndrome care and improve the utilization of guideline-directed medical therapy (GDMT). So, in this regard, there's no question that pharmacists will play a key role in the CKM interdisciplinary team and are going to be vital to its long-term success.
Pharmacy Times: Is there anything else that you would like to add?
Ndumele: One of the main goals in CKM syndrome is to move from isolated care to thinking about team-based, whole-person care. That means we need to bring together perspectives from multiple disciplines and multiple specialties and really make sure that all of those are represented in a way that meets the needs of the whole patient. Pharmacists play a key role in this regard, as well as other members of this interdisciplinary team, to make sure we're addressing all the needs for patients with interrelated conditions in the context of CKM syndrome.
REFERENCES
