American Diabetes Association updates recommendations regarding SGLT-2 inhibitors, GLP-1 RA, and finerenone for cardiovascular and renal comorbidities.
In late May 2022, the American Diabetes Association (ADA) released revisions to its previous guidelines. Although the core structure of diabetic treatment has remained the same, recommendations regarding sodium-glucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RA), and finerenone for cardiovascular and renal comorbidities have been significantly updated.1
SGLT-2 Inhibitors, GLP-1 RAs, and Finerenone: Roles in Treatment
Previously, an SGLT-2 inhibitor or a GLP-1 RA was only recommended for type 2 diabetes mellitus (T2DM) patients with current or high-risk potential for atherosclerotic cardiovascular disease (ASCVD) if additional glucose lowering was needed. Current guidelines now recommend these agents for any T2DM patient with current or high risk ASCVD, chronic kidney disease (CKD), or heart failure (HF).2 This guideline stands regardless of the need for additional glucose lowering and/or metformin use.
If patients with ASCVD remain above goal A1C despite the addition of an SGLT-2 inhibitor or GLP-1 RA, then the addition of a dipeptidyl peptidase-4 (DPP-4) inhibitor, basal insulin, or sulfonylureas as adjuncts should no longer be considered. Instead, either a GLP-1 inhibitor or SGLT-2 inhibitor—whichever agent the patient is not currently on—is recommended to add.3 Combined use of an SGLT-2 inhibitor and GLP-1 RA can produce an additive risk reduction for cardiovascular and renal adverse events.2
For renal benefit, finerenone use for patients with advanced CKD (i.e., moderately elevated albuminuria, eGFR of 25- 60 mL/min/1.73m2, and diabetic retinopathy or severely elevated albuminuria and eGFR of 25-75 mL/min/1.73m2) is encouraged.4,5
Patients with less-advanced CKD (i.e., stages 1-2 CKD with severely elevated albuminuria or stages 3-4 CKD with moderately elevated albuminuria) do not receive any benefit for CKD.6 Regardless of severity of CKD, SGLT-2 inhibitors remain first-line therapy.
Finerenone use for T2DM patients with CKD is limited as an adjunct to SGLT-2 inhibitors or for those intolerant to the first-line agent. Table 1 summarizes the clinical trials supporting these guidelines.
Finerenone (Kerendia) selectively blocks sodium reabsorption and overactivation of mineralocorticoid receptors within epithelial and non-epithelial tissues. This, in turn, reduces fibrosis and inflammation of both the kidneys and blood vasculature.
Barriers in use may include increased risk of hyperkalemia, hypotension, and high-cost ($22.76/tablet). For Mayo Health Plan members, finerenone is a tier 2R drug with prior authorization approvals limited to the FDA approved indication, CKD with T2DM.
About the Authors
Author: Jana Kay Lacanlale, PharmD Candidate, Drake University Class of 2024
Preceptor: Amanda Davis, PharmD, BCACP