Tim Pflederer, MD, of Evergreen Nephrology explains why proteinuria, diabetes, and heart failure all point toward the same two drug classes.
In an interview with Pharmacy Times, Tim Pflederer, MD, chief medical officer for Evergreen Nephrology, discussed how sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists have reshaped the approach to chronic kidney disease (CKD) and what providers should weigh before prescribing them.
Pflederer framed the shift around a central idea: CKD does not travel alone. Citing a New England Journal of Medicine research letter published this month, he noted that CKD prevalence has held steady while diabetes and heart failure are increasingly associated with the condition. That overlap means CKD is better understood as a cardiovascular-kidney-metabolic syndrome than as an isolated kidney problem. Both drug classes treat this syndrome, which is why he described them as having revolutionized nephrology's thinking.1
On patient selection, Pflederer took an expansive view. Most patients with CKD stand to benefit—those with proteinuria absolutely, and those with diabetes or heart failure as well. The relevant question is no longer whether a patient has diabetes, but whether they are at risk of progression or cardiovascular events.
The prescribing considerations he raised are practical and class-specific. Before starting an SGLT2 inhibitor, get the patient's diabetes under control: the drugs work by moving glucose into the urine, so uncontrolled diabetes means substantially more urination and a dehydration risk. With GLP-1 receptor agonists, start low and titrate slowly to limit gastrointestinal intolerance. Both errors share a consequence: patients start the therapy, stop it, and never see the benefit.
His counseling points followed the same logic. Patients on SGLT2 inhibitors should expect increased urination, watch for urinary tract infections (particularly women), report symptoms promptly, and contact their provider during illness, when the medication may need to be held if fluid intake cannot keep pace. Patients starting a GLP-1 should be told that gastrointestinal effects are expected and diminish over time—the counseling point that keeps them on therapy long enough to benefit.
